ClickCease
+1-915-850-0900 spinedoctors@gmail.com
Select Page
Rheumatoid Arthritis of the Cervical Spine

Rheumatoid Arthritis of the Cervical Spine

Rheumatoid arthritis, or RA, is a chronic health issue which affects approximately 1 percent of the population in the United States. RA is an autoimmune disorder that causes the inflammation and degeneration of the synovial tissue, specific cells and tissue which form the lining of the joints within the human body. Rheumatoid arthritis may and generally does affect every joint in the body, especially as people get older. RA commonly develops in the joints of the hands and feet, severely restricting an individual’s ability to move, however, those with significant disease in the spine are at risk of damage like paraplegia. Rheumatoid arthritis of the spine is frequent in three areas, causing different clinical problems.

The first is basilar invagination, also referred to as cranial settling or superior migration of the odontoid, a health issue where degeneration from rheumatoid arthritis at the base of the skull causes the it to “settle” into the spinal column, causing the compression or impingement of the spinal cord between the skull and the 1st cervical nerves. The second health issue, and also the most frequent, is atlanto-axial instability. A synovitis and erosion of the ligaments and joints connecting the 1st (atlas) and the 2nd (axis) cervical vertebrae causes instability of the joint, which may ultimately result in dislocation and spinal cord compression. In addition, a pannus, or localized mass/swelling of rheumatoid synovial tissue, can also form in this region, causing further spinal cord compression. The third health issues is a subaxial subluxation which causes the degeneration of the cervical vertebrae (C3-C7) and often results in other problems like spinal stenosis.

Imaging studies are crucial to properly diagnose patients with rheumatoid arthritis of the cervical spine. X-rays will demonstrate the alignment of the spine, and if there is obvious cranial settling or instability. It can also be difficult to demonstrate the anatomy at the bottom of the skull, therefore, computed tomography scanning, or CT scan, with an injection of dye within the thecal sac is arranged. Magnetic resonance imaging, or MRI, is beneficial to assess the severity of nerve compression or spinal cord injury, and allows visualization of structures, including the nerves, muscles, and soft tissues. Flexion/extension x-rays of the cervical spine are usually obtained to evaluate for signs of ligamentous instability. These imaging studies entails a plain lateral x-ray being taken with the patient bending forward and the other lateral x-ray being taken with the individual extending the neck backwards.�The scope of our information is limited to chiropractic, spinal injuries, and conditions. To discuss the subject matter, please feel free to ask Dr. Jimenez or contact us at�915-850-0900�.

Curated by Dr. Alex Jimenez

Green Call Now Button H .png

Additional Topics: Neck Pain and Auto Injury

Whiplash is one of the most common causes of neck pain after an automobile accident. A whiplash-associated disorder occurs when a person’s head and neck moves abruptly back-and-forth, in any direction, due to the force of an impact. Although whiplash most commonly occurs following a rear-end car crash, it can also result from sports injuries. During an auto accident, the sudden motion of the human body can cause the muscles, ligaments, and other soft tissues of the neck to extend beyond their natural range of motion, causing damage or injury to the complex structures surrounding the cervical spine. While whiplash-associated disorders are considered to be relatively mild health issues, these can cause long-term pain and discomfort if left untreated. Diagnosis is essential.

blog picture of cartoon paper boy

EXTRA EXTRA | IMPORTANT TOPIC: Neck Pain Chiropractic Treatment

Cervical Spine Radiographs in the Trauma Patient

Cervical Spine Radiographs in the Trauma Patient

While computed tomography scanning, or CT scans, of the cervical spine are frequently utilized to help diagnose neck injuries, simple radiographs are still commonly performed for patients who have experienced minor cervical spine injuries with moderate neck pain, such as those who have suffered a slip-and-fall accident. Imaging diagnostic assessments may reveal underlying injuries and/or aggravated conditions to be more severe than the nature of the trauma. The purpose of the article is to demonstrate the significance of cervical spine radiographs in the trauma patient.�

Abstract

Significant cervical spine injury is very unlikely in a case of trauma if the patient has normal mental status (including no drug or alcohol use) and no neck pain, no tenderness on neck palpation, no neurologic signs or symptoms referable to the neck (such as numbness or weakness in the extremities), no other distracting injury and no history of loss of consciousness. Views required to radiographically exclude a cervical spine fracture include a posteroanterior view, a lateral view and an odontoid view. The lateral view must include all seven cervical vertebrae as well as the C7-T1 interspace, allowing visualization of the alignment of C7 and T1. The most common reason for a missed cervical spine injury is a cervical spine radiographic series that is technically inadequate. The �SCIWORA� syndrome (spinal cord injury without radiographic abnormality) is common in children. Once an injury to the spinal cord is diagnosed, methylprednisolone should be administered as soon as possible in an attempt to limit neurologic injury.

Dr-Jimenez_White-Coat_01.png

Radiographs continue to be used as a first-line imaging diagnostic assessment modality in the evaluation of patients with suspected cervical spine injuries. The aim of cervical spine radiographs is to confirm the presence of a health issue in the complex structures of the neck and define its extent, particularly with respect to instability. Multiple views may generally be necessary to provide optimal visualization.

Dr. Alex Jimenez D.C., C.C.S.T.

Introduction

Although cervical spine radiographs are almost routine in many emergency departments, not all trauma patients with a significant injury must have radiographs, even if they arrive at the emergency department on a backboard and wearing a cervical collar. This article reviews the proper use of cervical spine radiographs in the trauma patient.

Low-risk criteria have been defined that can be used to exclude cervical spine fractures, based on the patient’s history and physical examination.1�6 Patients who meet these criteria (Table 1) do not require radiographs to rule out cervical fractures. However, the criteria apply only to adults and to patients without mental status changes, including drug or alcohol intoxication. Although studies suggest that these criteria may also be used in the management of verbal children,7�9 caution is in order, since the study series are small, and the ability of children to complain about pain or sensory changes is variable. An 18-year-old patient can give a more reliable history than a five-year-old child.

Some concern has been expressed about case reports suggesting that �occult� cervical spine fractures will be missed if asymptomatic trauma patients do not undergo radiography of the cervical spine.10 On review, however, most of the reported cases did not meet the low-risk criteria in Table 1. Attention to these criteria can substantially reduce the use of cervical spine radiographs.

Cervical Spine Series and Computed Tomography

Once the decision is made to proceed with a radiographic evaluation, the proper views must be obtained. The single portable cross-table lateral radiograph, which is sometimes obtained in the trauma room, should be abandoned. This view is insufficient to exclude a cervical spine fracture and frequently must be repeated in the radiographic department.11,12 The patient’s neck should remain immobilized until a full cervical spine series can be obtained in the radiographic department. Initial films may be taken through the cervical collar, which is generally radiolucent. An adequate cervical spine series includes three views: a true lateral view, which must include all seven cervical vertebrae as well as the C7-T1 junction, an anteroposterior view and an open-mouth odontoid view.13

If no arm injury is present, traction on the arms may facilitate visualization of all seven cervical vertebrae on the lateral film. If all seven vertebrae and the C7-T1 junction are not visible, a swimmer’s view, taken with one arm extended over the head, may allow adequate visualization of the cervical spine. Any film series that does not include these three views and that does not visualize all seven cervical vertebrae and the junction of C7-T1 is inadequate. The patient should be maintained in cervical immobilization, and plain films should be repeated or computed tomographic (CT) scans obtained until all vertebrae are clearly visible. The importance of obtaining all of these views and visualizing all of the vertebrae cannot be overemphasized. While some missed cervical fractures, subluxations and dislocations are the result of film misinterpretation, the most frequent cause of overlooked injury is an inadequate film series.14,15

In addition to the views listed above, some authors suggest adding two lateral oblique views.16,17 Others would obtain these views only if there is a question of a fracture on the other three films or if the films are inadequate because the cervicothoracic junction is not visualized.18 The decision to take oblique views is best made by the clinician and the radiologist who will be reviewing the films.

Besides identifying fractures, plain radiographs can also be useful in identifying ligamentous injuries. These injuries frequently present as a malalignment of the cervical vertebrae on lateral views. Unfortunately, not all ligamentous injuries are obvious. If there is a question of ligamentous injury (focal neck pain and minimal malalignment of the lateral cervical x-ray [meeting the criteria in Table 2]) and the cervical films show no evidence of instability or fracture, flexion-extension views should be obtained.17,19 These radiographs should only be obtained in conscious patients who are able to cooperate. Only active motion should be allowed, with the patient limiting the motion of the neck based on the occurrence of pain. Under no circumstance should cervical spine flexion and extension be forced, since force may result in cord injury.

Although they may be considered adequate to rule out a fracture, cervical spine radiographs have limitations. Up to 20 percent11,20,21 of fractures are missed on plain radiographs. If there is any question of an abnormality on the plain radiograph or if the patient has neck pain that seems to be disproportionate to the findings on plain films, a CT scan of the area in question should be obtained. The CT is excellent for identifying fractures, but its ability to show ligamentous injuries is limited.22 Occasionally, plain film tomography may be in order if there is a concern about a type II dens fracture (Figure 1).

While some studies have used magnetic resonance imaging (MRI) as an adjunct to plain films and CT scanning,23,24 the lack of wide availability and the relatively prolonged time required for MRI scanning limits its usefulness in the acute setting. Another constraint is that resuscitation equipment with metal parts may not be able to function properly within the magnetic field generated by the MRI.

Cervical Spine Radiography

Figure 2 summarizes the approach to reading cervical spine radiographs.

Lateral View

Alignment of the vertebrae on the lateral film is the first aspect to note (Figure 3). The anterior margin of the vertebral bodies, the posterior margin of the vertebral bodies, the spinolaminar line and the tips of the spinous processes (C2-C7) should all be aligned. Any malalignment (Figures 4 and 5) should be considered evidence of ligamentous injury or occult fracture, and cervical spine immobilization should be maintained until a definitive diagnosis is made.

Confusion can sometimes result from pseudosubluxation, a physiologic misalignment that is due to ligamentous laxity, which can occur at the C2-C3 level and, less commonly, at the C3-C4 level. While pseudosubluxation usually occurs in children, it also may occur in adults. If the degree of subluxation is within the normal limits listed in Table 2 and the neck is not tender at that level, flexion-extension views may clarify the situation. Pseudosubluxation should disappear with an extension view. However, flexion-extension views should not be obtained until the entire cervical spine is otherwise cleared radiographically.

After ensuring that the alignment is correct, the spinous processes are examined to be sure that there is no widening of the space between them. If widening is present, a ligamentous injury or fracture should be considered. In addition, if angulation is more than 11 degrees at any level of the cervical spine, a ligamentous injury or fracture should be assumed. The spinal canal (Figure 2) should be more than 13 mm wide on the lateral view. Anything less than this suggests that spinal cord compromise may be impending.

Next, the predental space�the space between the odontoid process and the anterior portion of the ring of C1 (Figure 2)�is examined. This space should be less than 3 mm in adults and less than 4 mm in children (Table 2). An increase in this space is presumptive evidence of a fracture of C1 or of the odontoid process, although it may also represent ligamentous injury at this level. If a fracture is not found on plain radiographs, a CT scan should be obtained for further investigation. The bony structures of the neck should be examined, with particular attention to the vertebral bodies and spinous processes.

The retropharyngeal space (Figure 2) is now examined. The classic advice is that an enlarged retropharyngeal space (Table 2) indicates a spinous fracture. However, the normal and abnormal ranges overlap significantly.25 Retropharyngeal soft tissue swelling (more than 6 mm at C2, more than 22 mm at C6) is highly specific for a fracture but is not very sensitive.26 Soft tissue swelling in symptomatic patients should be considered an indication for further radiographic evaluation. Finally, the craniocervical relationship is checked.

Odontoid View

The dens is next examined for fractures. Artifacts may give the appearance of a fracture (either longitudinal or horizontal) through the dens. These artifacts are often radiographic lines caused by the teeth overlying the dens. However, fractures of the dens are unlikely to be longitudinally oriented. If there is any question of a fracture, the view should be repeated to try to get the teeth out of the field. If it is not possible to exclude a fracture of the dens, thin-section CT scans or plain film tomography is indicated.

Next, the lateral aspects of C1 are examined. These aspects should be symmetric, with an equal amount of space on each side of the dens. Any asymmetry is suggestive of a fracture. Finally, the lateral aspects of C1 should line up with the lateral aspects of C2. If they do not line up, there may be a fracture of C1. Figure 6 demonstrates asymmetry in the space between the dens and C1, as well as displacement of the lateral aspects of C1 laterally.

Anteroposterior View

The height of the cervical spines should be approximately equal on the anteroposterior view. The spinous processes should be in midline and in good alignment. If one of the spinous processes is off to one side, a facet dislocation may be present.

Common Cervical Abnormalities

The most common types of cervical abnormalities and their radiographic findings are listed in Table 3. Except for the clay shoveler’s fracture, they should be assumed to be unstable and warrant continued immobilization until definitive therapy can be arranged. Any patient found to have one spinal fracture should have an entire spine series, including views of the cervical spine, the thoracic spine and the lumbosacral spine. The incidence of noncontiguous spine fractures ranges up to 17 percent.27,28 Figures 7 through 9 demonstrate aspects of common cervical spine fractures.

Initial Treatment of Cervical Spine and Cord

If a cervical fracture or dislocation is found, orthopedic or neurosurgical consultation should be obtained immediately. Any patient with a spinal cord injury should begin therapy with methylprednisolone within the first eight hours after the injury, with continued administration for up to 24 hours. Patients should receive methylprednisolone in a dosage of 30 mg per kg given intravenously over one hour. Over the next 23 hours, intravenous methylprednisolone in a dosage of 5.4 mg per kg per hour should be administered. This therapy has been shown to improve outcomes and minimize cord injury,29 although it is not without its problems. The incidence of pneumonia is increased in patients treated with high dosages of methylprednisolone.30

�Sciwora� Syndrome: Unique in Children

A special situation involving children deserves mention. In children, it is not uncommon for a spinal cord injury to show no radiographic abnormalities. This situation has been named �SCIWORA� (spinal cord injury without radiographic abnormality) syndrome. SCIWORA syndrome occurs when the elastic ligaments of a child’s neck stretch during trauma. As a result, the spinal cord also undergoes stretching, leading to neuronal injury or, in some cases, complete severing of the cord.31 This situation may account for up to 70 percent of spinal cord injuries in children and is most common in children younger than eight years. Paralysis may be present on the patient’s arrival in the emergency department. However, up to 30 percent of patients have a delayed onset of neurologic abnormalities, which may not occur until up to four or five days after the injury. In patients with delayed symptoms, many have neurologic symptoms at the time of the injury, such as paresthesias or weakness, that have subsequently resolved.32

It is important to inform the parents of young patients with neck trauma about this possibility so that they will be alert for any developing symptoms or signs. Fortunately, most children with SCIWORA syndrome have a complete recovery, especially if the onset is delayed.33 It is possible to evaluate these injuries with MRI, which will show the abnormality and help determine the prognosis: a patient with complete cord transection is unlikely to recover.3

The treatment of SCIWORA syndrome has not been well studied. However, the general consensus is that steroid therapy should be used.34 In addition, any child who has sustained a significant degree of trauma but has recovered completely should be restricted from physical activities for several weeks.34

Dr Jimenez White Coat

Cervical spine radiographs include three standard views, such as the coned odontoid peg view, the anteroposterior view of the entire cervical spine, and the lateral view of the entire cervical spine. Most qualified and experienced healthcare professionals, including chiropractors, offer additional views to visualize the cervicothoracic junction as well as to evaluate the proper alignment of the spine in all patients.�

Dr. Alex Jimenez D.C., C.C.S.T.

About the Authors

MARK A. GRABER, M.D., is associate professor of clinical family medicine and surgery (emergency medicine) at the University of Iowa Hospitals and Clinics, Iowa City. He received his medical degree from Eastern Virginia Medical School, Norfolk, and served a residency in family medicine at the University of Iowa College of Medicine, Iowa City.

MARY KATHOL, M.D., is associate professor of radiology at the University of Iowa Hospitals and Clinics. She is also head of the musculoskeletal radiology section. She received her medical degree from the University of Kansas School of Medicine, Kansas City, Kan., and served a residency in radiology at the University of Iowa College of Medicine.

Address correspondence to Mark A. Graber, M.D., Department of Family Medicine, Steindler Bldg., University of Iowa Hospitals and Clinics, Iowa City, Iowa 52242. Reprints are not available from the authors.

In conclusion,�it is essential to evaluate all views of the cervical spine through imaging diagnostic assessments. While cervical spine radiographs can reveal injuries and conditions, not all neck injuries are detected through radiography. Computed tomography, or CT, scans of the cervical spine are highly accurate in the diagnosis of neck fractures which can help with treatment. The scope of our information is limited to chiropractic as well as to spinal injuries and conditions. To discuss the subject matter, please feel free to ask Dr. Jimenez or contact us at�915-850-0900�.

Curated by Dr. Alex Jimenez

Green Call Now Button H .png

Additional Topics: Acute Back Pain

Back pain�is one of the most prevalent causes of disability and missed days at work worldwide. Back pain attributes to the second most common reason for doctor office visits, outnumbered only by upper-respiratory infections. Approximately 80 percent of the population will experience back pain at least once throughout their life. The spine is a complex structure made up of bones, joints, ligaments, and muscles, among other soft tissues. Because of this, injuries and/or aggravated conditions, such as�herniated discs, can eventually lead to symptoms of back pain. Sports injuries or automobile accident injuries are often the most frequent cause of back pain, however, sometimes the simplest of movements can have painful results. Fortunately, alternative treatment options, such as chiropractic care, can help ease back pain through the use of spinal adjustments and manual manipulations, ultimately improving pain relief.

 

blog picture of cartoon paper boy

EXTRA EXTRA | IMPORTANT TOPIC: Chiropractic Neck Pain Treatment

Blank
References

1.�Kreipke DL, Gillespie KR, McCarthy MC, Mail JT, Lappas JC, Broadie TA. Reliability of indications for cervical spine films in trauma patients.�J Trauma. 1989;29:1438�9.

2.�Ringenberg BJ, Fisher AK, Urdaneta LF, Midthun MA. Rational ordering of cervical spine radiographs following trauma.�Ann Emerg Med. 1988;17:792�6.

3.�Bachulis BL, Long WB, Hynes GD, Johnson MC. Clinical indications for cervical spine radiographs in the traumatized patient.�Am J Surg. 1987;153:473�8.

4.�Hoffman JR, Schriger DL, Mower W, Luo JS, Zucker M. Low-risk criteria for cervical-spine radiography in blunt trauma: a prospective study.�Ann Emerg Med. 1992;21:1454�60.

5.�Saddison D, Vanek VW, Racanelli JL. Clinical indications for cervical spine radiographs in alert trauma patients.�Am Surg. 1991;57:366�9.

6.�Kathol MH, El-Khoury GY. Diagnostic imaging of cervical spine injuries.�Seminars in Spine Surgery. 1996;8(1):2�18.

7.�Lally KP, Senac M, Hardin WD Jr, Haftel A, Kaehler M, Mahour GH. Utility of the cervical spine radiograph in pediatric trauma.�Am J Surg. 1989;158:540�1.

8.�Rachesky I, Boyce WT, Duncan B, Bjelland J, Sibley B. Clinical prediction of cervical spine injuries in children. Radiographic abnormalities.�Am J Dis Child. 1987;141:199�201.

9.�Laham JL, Cotcamp DH, Gibbons PA, Kahana MD, Crone KR. Isolated head injuries versus multiple trauma in pediatric patients: do the same indications for cervical spine evaluation apply?�Pediatr Neurosurg. 1994;21:221�6.

10.�McKee TR, Tinkoff G, Rhodes M. Asymptomatic occult cervical spine fracture: case report and review of the literature.�J Trauma. 1990;30:623�6.

11.�Woodring JH, Lee C. Limitations of cervical radiography in the evaluation of acute cervical trauma.�J Trauma. 1993;34:32�9.

12.�Spain DA, Trooskin SZ, Flancbaum L, Boyarsky AH, Nosher JL. The adequacy and cost effectiveness of routine resuscitation-area cervical-spine radiographs.�Ann Emerg Med. 1990;19:276�8.

13.�Tintinalli JE, Ruiz E, Krome RL, ed. Emergency medicine: a comprehensive study guide. 4th ed. New York: McGraw-Hill, 1996.

14.�Gerrelts BD, Petersen EU, Mabry J, Petersen SR. Delayed diagnosis of cervical spine injuries.�J Trauma. 1991;31:1622�6.

15.�Davis JW, Phreaner DL, Hoyt DB, Mackersie RC. The etiology of missed cervical spine injuries.�J Trauma. 1993;34:342�6.

16.�Apple JS, Kirks DR, Merten DF, Martinez S. Cervical spine fractures and dislocations in children.�Pediatr Radiol. 1987;17:45�9.

17.�Turetsky DB, Vines FS, Clayman DA, Northup HM. Technique and use of supine oblique views in acute cervical spine trauma.�Ann Emerg Med. 1993;22:685�9.

18.�Freemyer B, Knopp R, Piche J, Wales L, Williams J. Comparison of five-view and three-view cervical spine series in the evaluation of patients with cervical trauma.�Ann Emerg Med. 1989;18:818�21.

19.�Lewis LM, Docherty M, Ruoff BE, Fortney JP, Keltner RA Jr, Britton P. Flexion-extension views in the evaluation of cervical-spine injuries.�Ann Emerg Med. 1991;20:117�21.

20.�Mace SE. Emergency evaluation of cervical spine injuries: CT versus plain radiographs.�Ann Emerg Med. 1985;14:973�5.

21.�Kirshenbaum KJ, Nadimpalli SR, Fantus R, Cavallino RP. Unsuspected upper cervical spine fractures associated with significant head trauma: role of CT.�J Emerg Med. 1990;8:183�98.

22.�Woodring JH, Lee C. The role and limitations of computed tomographic scanning in the evaluation of cervical trauma.�J Trauma. 1992;33:698�708.

23.�Schaefer DM, Flanders A, Northrup BE, Doan HT, Osterholm JL. Magnetic resonance imaging of acute cervical spine trauma. Correlation with severity of neurologic injury.�Spine. 1989;14:1090�5.

24.�Levitt MA, Flanders AE. Diagnostic capabilities of magnetic resonance imaging and computed tomography in acute cervical spinal column injury.�Am J Emerg Med. 1991;9:131�5.

25.�Templeton PA, Young JW, Mirvis SE, Buddemeyer EU. The value of retropharyngeal soft tissue measurements in trauma of the adult cervical spine. Cervical spine soft tissue measurements.�Skeletal Radiol. 1987;16:98�104.

26.�DeBehnke DJ, Havel CJ. Utility of prevertebral soft tissue measurements in identifying patients with cervical spine fractures.�Ann Emerg Med. 1994;24:1119�24.

27.�Powell JN, Waddell JP, Tucker WS, Transfeldt EE. Multiple-level noncontiguous spinal fractures.�J Trauma. 1989;29:1146�50.

28.�Keenen TL, Antony J, Benson DR. Non-contiguous spinal fractures.�J Trauma. 1990;30:489�91.

29.�Bracken MB, Shepard MJ, Collins WF Jr, Holford TR, Baskin DS, Eisenberg HM, et al. Methylprednisolone or naloxone treatment after acute spinal cord injury: 1-year follow-up data. Results of the second National Acute Spinal Cord Injury Study.�J Neurosurg. 1992;76:23�31.

30.�Galandiuk S, Raque G, Appel S, Polk HC Jr. The two-edged sword of large-dose steroids for spinal cord trauma.�Ann Surg. 1993;218:419�25.

31.�Grabb PA, Pang D. Magnetic resonance imaging in the evaluation of spinal cord injury without radiographic abnormality in children.�Neurosurgery. 1994;35:406�14.

32.�Pang D, Pollack IF. Spinal cord injury without radiographic abnormality in children�the SCIWORA syndrome.�J Trauma. 1989;29:654�64.

33.�Hadley MN, Zabramski JM, Browner CM, Rekate H, Sonntag VK. Pediatric spinal trauma. Review of 122 cases of spinal cord and vertebral column injuries.�J Neurosurg. 1988;68:18�24.

34.�Kriss VM, Kriss TC. SCIWORA (spinal cord injury without radiographic abnormality) in infants and children.�Clin Pediatr. 1996;35:119�24.

The editors of AFP welcome the submission of manuscripts for the Radiologic Decision-Making series. Send submissions to Jay Siwek, M.D., following the guidelines provided in �Information for Authors.�

Coordinators of this series are Thomas J. Barloon, M.D., associate professor of radiology and George R. Bergus, M.D., assistant professor of family practice, both at the University of Iowa College of Medicine, Iowa City.

Close Accordion
Neck Pain Treatment Management

Neck Pain Treatment Management

I do recommend that you seek a specialist, in this case, it would be Dr. Alex Jimenez. His techniques to work on the cervical area or your neck are just amazing. He has been able to treat migraines, shoulder pain, when people didn’t know it was just a simple cause…spraining their neck.

Sandra Rubio

Have you ever woken up with a stiff neck, unable to turn it to one side or another? Does your child appear to have an abnormal head or neck posture? A variety of factors can cause injuries and/or conditions which may result in neck pain, such as�torticollis, a painful health issue that can result in the shortening of the complex structures of the neck.

The neck, known as the cervical spine, consists of vertebrae that start in the upper region of the spine and finish at the base of the skull. Each bony vertebrae connects with ligaments, comparable to thick rubber bands, muscles and other soft tissues like tendons, which provide stability to the backbone. These structures ultimately permit for movement and support.

The neck supports the weight of the head and provides significant motion. Because it is less protected than the rest of the spine, the neck may be vulnerable�to injury or conditions. For many individuals, neck pain is a temporary condition that vanishes with time. However, others need diagnosis and treatment to relieve their symptoms. Below, we will discuss some of the most common causes of neck pain, including torticollis.

Common Causes of Neck Pain

Neck pain may result from abnormalities in the soft tissues, such as the muscles, ligaments, tendons and even the nerves, as well as in the bones and intervertebral discs of the spine. The most frequent causes of neck pain are soft-tissue abnormalities due to trauma, known as a sprain or strain, or due to prolonged wear and tear or degeneration. In rare cases, infection or tumors can cause neck pain. In certain people, neck problems may be the origin of pain at the back, shoulders, or upper extremities.

Cervical Disk Degeneration (Spondylosis)

The intervertebral discs act as shock absorbers between the bones in the neck. In cervical disk degeneration, which generally occurs in people over the age of 40, the gel-like center of the disc degenerates and the distance between the vertebrae narrows. When�the disc space becomes narrower, stress accumulates in the joints of the spine, resulting in degenerative diseases, such as cervical disk degeneration or spondylosis. Once the outer layer of the disc weakens, stress may also protrude and place pressure on the spinal cord or nerve roots. This is known as a herniated disc.

Neck Injury

Since the primary function of the neck is to support the head and provide movement, it’s very flexible, however, because of this, it’s incredibly vulnerable to�injury. Automobile accidents, slip-and-fall incidents, and sports injuries may commonly cause neck pain. The regular use of safety belts in motor vehicles can help prevent neck injury. A “rear end” car crash may result in whiplash, a common neck injury characterized by�a sudden, back-and-forth jerk of the neck and head from�a sheer force. Most neck injuries involve the soft tissues. Severe neck injuries with dislocation or a fracture of the neck may damage the spinal cord and cause paralysis.

Torticollis

Torticollis is a medical health issue characterized by a “twisted neck”. There are two kinds of the condition, congenital, meaning present at birth, and acquired, involving damage or trauma from an injury or condition. For many infants, torticollis develops in the womb several weeks before their birth at which neck and the head are positioned in an angle.

Children have also been born with the health issue due�to difficulties during delivery, diminished blood supply to the neck muscles, muscular fibrosis or congenital spine anomalies. According to research studies, torticollis sometimes develops in children that spend too much time sitting in strollers, swings, bouncers, car seats, laying on their back, or putting them on mats if a child is born with abnormal head and neck positioning.

While nearly all people who experience torticollis are babies or children, anyone can experience neck pain and restricted range of motion connected with that. A musculoskeletal or nervous system injury can make it difficult to position your head or to straighten your neck. This kind of damage may be associated with prolonged ailments, car accidents or other injuries.

When to Seek Treatment for Neck Pain?

If severe neck pain occurs after a neck injury due to an automobile accident, diving injury,�or slip-and-fall incident, a trained professional, such as a paramedic, should trap the patient to prevent the risk of further harm and possible paralysis. Immediate medical assistance should be considered. Healthcare professionals, like chiropractors, can also treat neck injuries.

Immediate medical care must also be sought when an injury causes pain in the neck which radiates down the arms and legs. Radiating pain or tingling sensations in your arms and legs resulting in weakness and numbness without especially neck pain should also be assessed as soon as possible. If there is no injury, you should seek medical attention when neck pain is:

  • Constant and persistent
  • Severe
  • Accompanied by pain which radiates down the arms or legs
  • Accompanied by headaches, tingling, weakness or numbness

Many patients seek treatment for neck pain with healthcare professionals that are specially trained to diagnose, treat, and prevent problems between the muscles, bones, joints, ligaments, tendons, and nerves. Many treat a wide variety of injuries and conditions. Chiropractic care is a popular, alternative treatment option which can help treat neck pain.

Torticollis Treatment

For most adults, torticollis will solve itself on its own in a couple of days. However, it is essential to seek treatment on behalf of babies or children who are currently experiencing this kind of neck or head positioning. Infants may suffer permanent disability because of shortening neck muscles if left without treatment for torticollis.

One of the first treatments doctors advocate stretching exercises designed to lengthen and strengthen the neck muscles holding the head in the position. About 80 percent of all children respond well to this kind of treatment program and don’t experience any effects. Once completed, the infant might require�other treatment modalities to prevent the problem from recurring and to strengthen their neck muscles.

Dr-Jimenez_White-Coat_01.png

Neck pain is one of the most common health issues treated with chiropractic care. According to the National Institute of Health Statistics, neck pain is the second most prevalent form of pain in the United States, following back pain associated with migraine and headaches. Chiropractic care can help treat a variety of injuries and conditions which may be causing neck pain, including torticollis.

Dr. Alex Jimenez D.C., C.C.S.T.

Chiropractic Care for Torticollis

Chiropractic care is a well-known, alternative treatment approach designed to increase range of motion, decrease muscle stiffness and improve fine and gross motor abilities needed for neck and head placement. A chiropractor will first conduct an assessment to test the patient’s range of motion and evaluate any other problems associated with neck pain.

In the case of torticollis, by way of instance, complications may include plagiocephaly, abnormal head shape, or a misalignment of the hip joint, known as hip dysplasia. When the evaluation is done, the healthcare professional will discuss a potential treatment plan and their findings.

Chiropractic care utilizes spinal adjustments and manual manipulations as well as exercises to increase range of motion and strengthen the patient’s neck muscles. These can consist of passive stretches designed to strengthen muscles which are used to maintain the�posture of the neck. In infants who do not appear to be strong enough to hold their head, stretching exercises may correct the problem. Early intervention is recommended.

If you or your child are experiencing debilitating neck pain or incorrect positioning of the head and neck, contact a healthcare professional immediately.�The scope of our information is limited to chiropractic as well as to spinal injuries and conditions. To discuss the subject matter, please feel free to ask Dr. Jimenez or contact us at�915-850-0900�.

Curated by Dr. Alex Jimenez

Green Call Now Button H .png

Additional Topics: Acute Back Pain

Back pain�is one of the most prevalent causes of disability and missed days at work worldwide. Back pain attributes to the second most common reason for doctor office visits, outnumbered only by upper-respiratory infections. Approximately 80 percent of the population will experience back pain at least once throughout their life. The spine is a complex structure made up of bones, joints, ligaments, and muscles, among other soft tissues. Because of this, injuries and/or aggravated conditions, such as�herniated discs, can eventually lead to symptoms of back pain. Sports injuries or automobile accident injuries are often the most frequent cause of back pain, however, sometimes the simplest of movements can have painful results. Fortunately, alternative treatment options, such as chiropractic care, can help ease back pain through the use of spinal adjustments and manual manipulations, ultimately improving pain relief.

 

blog picture of cartoon paper boy

EXTRA IMPORTANT TOPIC: Neck Pain Chiropractic Treatment

Understanding Neck Pain and Headaches

Understanding Neck Pain and Headaches

My treatment with Dr. Alex Jimenez has been helping me by simply making me less tired. I’m not experiencing as many headaches. The headaches are going down dramatically and my back feels much better. I would highly recommend Dr. Alex Jimenez. He’s very friendly, his staff is very friendly and everybody goes well beyond what they can do to help you. -�Shane Scott

 

A majority of the populations has suffered from this well-known nagging health issue, however, did you know that headaches can sometimes be caused by neck pain? While these headaches are commonly referred to as as cervicogenic headaches, other types of headaches, such as cluster headaches and even migraines, have also been determined to be caused by neck pain. Neck pain can develop due to a variety of reasons and it can vary tremendously from mild to severe.

 

Therefore, it’s fundamental to seek a proper diagnosis if you’ve experienced headaches or neck pain to determine the root cause of your symptoms as well as to properly determine what treatment option will be best for your specific health issue. Healthcare professionals will assess your upper back, or the cervical spine, including your neck, base of the skull and cranium, and also all the surrounding muscles and nerves to find the source of your symptoms. Before seeking help from a doctor, however, it’s important to understand how neck pain can cause headaches. Below, we will discuss the anatomy of the cervical spine, or neck, as well as demonstrate how neck pain is connected to headaches.

 

How Neck Pain Causes Headaches

 

The muscles located between the shoulder blades, upper portion of the shoulders and those surrounding the neck, or cervical spine, may all cause neck pain if they become too tight or stiff. This can generally occur due to trauma or damage from an injury, as well as in consequence to bad posture or poor sitting, lifting or work habits. The tight muscles will result in your neck joints feeling stiff or compressed and it can even radiate pain towards your shoulders. Over time, the balance of the neck muscles changes and those specific muscles which are meant to support the neck become weak and can ultimately begin to make the head start to feel heavy, increasing the risk of experiencing neck pain as well as headaches..

 

Furthermore, the roots of the upper 3 cervical spinal nerves, which are found at C1, C2, and C3, share a pain nucleus, which routes pain signals to the brain, along with the trigeminal nerve. The trigeminal nerve is the main sensory nerve that is in charge of carrying messages from the face to your brain. Because of the shared nerve tracts, pain is misunderstood and thus “felt” by the brain as being located in the head. Fortunately, many healthcare professionals�are experienced in the assessment and correction of muscular imbalances which may lead to neck pain and headaches. Moreover, they can help to relieve muscle tension, enhance muscle length and joint mobility, and retrain correct posture.

 

What Causes Neck Pain and Headaches?

 

Cervicogenic headaches, otherwise known as “neck headaches”, are caused by painful neck joints, tendons or other structures surrounding the neck, or cervical spine, which may refer pain to the bottom of the skull, to your face or head. Researchers believe that neck headaches, or cervicogenic headaches, account for approximately 20 percent of all headaches diagnosed clinically. Cervicogenic headaches and neck pain are closely associated with each other, although other types of headaches can also cause neck pain.

 

This type of head pain generally starts because of an injury, stiffness or lack of proper functioning of the joints found at the top of your neck, as well as tight neck muscles or swollen nerves, which could trigger pain signals that the brain then interprets as neck pain. The usual cause of neck headaches is dysfunction in the upper three neck joints, or 0/C1, C1/C2, C2/C3, including added tension in the sub-occipital muscles. Other causes for cervicogenic headaches and neck pain can include:

 

  • Cranial tension or trauma
  • TMJ (JAW) tension or altered bite
  • Stress
  • Migraine headaches
  • Eye strain

 

The Link Between Migraines and Neck Pain

Neck pain and migraines also have an intricate connection with each other. While in some cases, severe trauma, damage or injury to the neck can lead to severe headaches like migraine, in other situations neck pain might be the result of a migraine headache. However, it’s never a good idea to assume that one is the end result of the other. Seeking treatment for neck pain when the reason for your concern is in fact a migraine, often will not lead to effective pain management or pain relief. The best thing that you can do if you’re experiencing neck pain and headaches is to seek immediate medical attention from a specialized healthcare professional in order to determine the cause of your pain, as well as to determine the root cause of the symptoms.

 

Unfortunately, neck pain, as well as a variety of headaches, are commonly misdiagnosed or even sometimes go undiagnosed for an extended period of time. As a matter of fact, one of the top reasons as to why neck pain may be so difficult to treat is primarily because it takes a long time for people to take this health issue seriously and seek a proper diagnosis. Waiting an extended amount of time to take care of your neck pain, especially after an injury, may lead to acute pain and it may even make the symptoms more difficult to control, turning them into chronic pain. By the time a patient seeks diagnosis for their neck pain, it may have already been a persistent problem. Also, the most frequent reasons people seek treatment for neck pain and headaches include:

 

  • Chronic migraines and headaches
  • Restricted neck function, including difficulties moving the head
  • Soreness in the neck, upper back and shoulders
  • Stabbing pain and other symptoms, particularly in the neck
  • Pain radiating from the neck and shoulders to the fingertips

 

Aside from the symptoms mentioned above, individuals with neck pain and headaches can also experience additional symptoms, including nausea, diminished eyesight, difficulty concentrating, severe fatigue, and even difficulty sleeping.While there are circumstances in which the cause of your headaches or neck pain may be apparent, such as being in a recent automobile accident or suffering from sport-related trauma, damage or injuries, in several instances, the cause may not be quite as obvious.

 

Because neck pain and headaches can also develop as a result of bad posture or even due to nutritional problems, it’s fundamental to find�the origin of the pain to increase the success of treatment, in addition to enabling you to prevent the health issue from happening again in the future. It’s common for a healthcare professional to devote their time working with you to ascertain what could have caused the pain in the first place.

 

A Health Issue You Can’t Ignore

 

Neck pain is typically not a problem which should be ignored. You may think that you’re only experiencing minor neck discomfort and that it’s irrelevant to any other health issues you may be having, but more frequently than not, you can’t know for sure till you receive a proper diagnosis for your symptoms. Patients who seek immediate medical attention and treatment for their neck-centered problems are surprised to learn that some of the other health issues they may be experiencing may actually be correlated, such as in the case of neck pain and headaches. Thus, even in the event that you think you can “live with” not being able to turn your neck completely, other health issues can develop, and these problems might be more challenging to deal with.

 

There are circumstances in which a pinched nerve in the neck is the main reason for chronic tension headaches, where a previous sports injury that was not properly addressed before is now the cause of the individual’s limited neck mobility and in which a bruised vertebrae at the base of the neck induces throbbing sensations throughout the spine, which radiates through the shoulders into the arms, hands and fingers. You might also blame your chronic migraines on a hectic schedule and stressful conditions, however, it might truly be a consequence of poor posture and the obligated hours that you spend hunched over a computer screen.�Untreated neck pain might even lead to problems you might never expect, such as balance problems or trouble gripping objects. This is because all the neural roots located on the upper ligaments of the cervical spine, or neck, are connected to other parts of the human body, from your biceps to each one of your small fingers.

 

Working with a healthcare professional to relieve the root cause of your neck pain and headaches may significantly enhance your quality of life and may be able to eliminate other symptoms from turning into a significant problem. While the most common causes of chronic migraines are generally caused by another health issue or nutritional deficiency, you might also be amazed to learn how often the outcome is something which may be resolved with concentrated exercises and stretches recommended by a healthcare professional, such as a chiropractor. Additionally, you may understand that the health issues you’ve been having often develop from compressed, pinched, irritated or inflamed nerves in your upper cervical nerves.

 

Dr-Jimenez_White-Coat_01.png

Dr. Alex Jimenez’s Insight

Although it may be difficult to distinguish the various types of headaches, neck pain is generally considered to be a common symptom associated with head pain. Cervicogenic headaches are very similar to migraines, however, the primary difference between these two types of head pain is that a migraine occurs in the brain while a cervicogenic headache occurs in the base of the skull or in the cervical spine, or neck. Furthermore, some headaches may be caused by stress, tiredness, eyestrain and/or trauma or injury along the complex structures of the cervical spine, or neck. If you are experiencing neck pain and headaches, it’s important to seek help from a healthcare professional in order to determine the true cause of your symptoms.

 

Treatment for Neck Pain and Headaches

 

Foremost, a healthcare professional must�determine the cause of an individual’s symptoms through the use of appropriate diagnostic tools as well as to make sure they have the utmost success in relieving the headache and neck pain without prolonging the duration of the symptoms and extra cost of incorrect therapy. Once an individual’s source of neck pain and headaches has been diagnosed, the kind of treatment a patient receives ought to be dependent on the type of headache. As a rule of thumb, treatment starts once the diagnosis has been made.�A healthcare professional will work with you to create a treatment plan that’s appropriate for your specific health issues. In your sessions, you’ll be taken through procedures that help build flexibility and strength.

 

Chiropractic care is a well-known, alternative treatment option which focuses on the diagnosis, treatment and prevention of a variety of musculoskeletal and nervous system injuries and/or conditions. A doctor of chiropractic, or chiropractor, can help treat neck pain and headache symptoms by carefully correcting any spinal misalignments, or subluxations, in the cervical spine or neck, through the use of spinal adjustments and manual manipulations, among other therapeutic techniques. Chiropractors, as well as physical therapists, may also utilize�a combination of gentle Muscle Energy Techniques, muscle building, joint slides, cranio-sacral therapy, and specific posture and muscle re-education to lower the strain being placed on the structures surrounding the cervical spine.�The staff will also help you understand how to better position yourself during your daily life to prevent relapses, like ergonomic and posture tips. Contact a healthcare professional in order for them to be able to assist you immediately.

 

In cases where alternative treatment options have been utilized without any results, or sometimes simply being used together with other complementary treatment approaches, pain drugs and/or medications may be contemplated, such as non-steroidal anti-inflammatory drugs (NSAIDs), anti-seizure agents such as gabapentin, tricyclic anti-depressants, or migraine prescriptions. If pain medications prove ineffective, then injections may be contemplated, including peripheral nerve blocks, atlantoaxial joint block administered at C1-C2, or aspect joint blocks administered in C2-C3. Surgical interventions may also be other treatment options, however, healthcare professionals suggest attempting all other treatment options before considering surgery.�The scope of our information is limited to chiropractic as well as to spinal injuries and conditions. To discuss the subject matter, please feel free to ask Dr. Jimenez or contact us at�915-850-0900�.

 

Curated by Dr. Alex Jimenez

Green-Call-Now-Button-24H-150x150-2-3.png

Additional Topics: Back Pain

 

Back pain is one of the most prevalent causes for disability and missed days at work worldwide. As a matter of fact, back pain has been attributed as the second most common reason for doctor office visits, outnumbered only by upper-respiratory infections. Approximately 80 percent of the population will experience some type of back pain at least once throughout their life. The spine is a complex structure made up of bones, joints, ligaments and muscles, among other soft tissues. Because of this, injuries and/or aggravated conditions, such as herniated discs, can eventually lead to symptoms of back pain. Sports injuries or automobile accident injuries are often the most frequent cause of back pain, however, sometimes the simplest of movements can have painful results. Fortunately, alternative treatment options, such as chiropractic care, can help ease back pain through the use of spinal adjustments and manual manipulations, ultimately improving pain relief.

 

 

 

blog picture of cartoon paperboy big news

 

EXTRA IMPORTANT TOPIC:�Chiropractic Neck Pain Treatment�

 

 

Active Release Technique (A.R.T.) for Chronic Neck Pain in El Paso, TX

Active Release Technique (A.R.T.) for Chronic Neck Pain in El Paso, TX

Active Release Technique (A.R.T) is a hands on soft tissue treatment for ligaments, tendons muscles and nerves. It is the leading soft tissue treatment utilized widely in the treatment of soft tissue injuries and conditions among professional athletes and the general population alike. In the instance of chronic neck pain, along with shoulder and subscapularis pain, ART involves guided pressure being applied to a shortened muscle in the top region of the neck or cervical spine. Most commonly, a healthcare professional will move the patient’s head in a direction that lengthens the muscle. During the motion the doctor maintains a strain on the muscle, as it slides out from beneath the doctor’s fingers.

 

The active release technique hurts a bit (many patients describe it as a”good hurt”), and it feels like a stretch that you need but can’t do yourself. When a muscle is tight the procedure operates by increasing the nervous system’s tolerance to extend the muscle. ART is utilized to take care of repetitive strain injuries, and it is often used in a variety of other medical practices. This is because it can offer quick results in treating ailments like: tennis elbow, frozen shoulder, shoulder rotator cuff injuries and plantar fasciitis. ART permits the physician to isolate treatment to each individual small muscle of the neck, and treat it through its full selection of movement. The neck muscles are layered, and also to isolate them during therapy demands careful attention.

 

Effects of the Active Release Technique on Pain and Range of Motion in Patients with Chronic Neck Pain

 

Abstract

 

  • Purpose: To compare the influences of the active release technique (ART) and joint mobilization (JM) on the visual analog scale (VAS) pain score, pressure pain threshold (PPT), and neck range of motion (ROM) of patients with chronic neck pain.
  • Subjects: Twenty-four individuals with chronic neck pain were randomly and equally assigned to 3 groups: an ART group, a joint mobilization (JM) group, and a control group. Before and after the intervention, the degree of pain, PPT, and ROM of the neck were measured using a VAS, algometer, and goniometer, respectively.
  • Results: The ART group and JM group demonstrated significant changes in VAS and ROM between pre and post-intervention, while no significant change was observed in the control group. Significant differences in the PPT of all muscles were found in the ART group, while significant differences in all muscles other than the trapezius were found in the JM group. No significant difference in PPT was observed in any muscle of the control group. The posthoc test indicated no statistically significant difference between the ART and JM group, but the differences of variation in VAS, PPT, and ROM were greater in the ART group than in the JM and control groups.
  • Conclusion: ART for the treatment of chronic neck pain may be beneficial for neck pain and movement.
  • Key words: Active release technique, Soft tissue, Chronic neck pain

 

Introduction

 

People have a 70% likelihood of developing neck pain during their lives; thus, neck pain is an important issue affecting economic productivity in modern society[1]. Neck pain is a work-related musculoskeletal disorder that can occur when a person works for a long time or at a high intensity. An increasing number of patients also visit hospitals complaining of pain occurring not only in the neck but also in the upper extremities and head as a result of sustained excessive tension[2]. Although the issue of neck pain is becoming increasingly common and important, research into optimal treatmentslacking[3].

 

A common cause of neck pain is mechanical dysfunction, which causes abnormal joint movement, as abnormal cervical joint mobility inside the joint capsule can limit neck movement[4, 5]. Additionally, unbalanced soft tissue around the head and neck structure can place limits on the range of motion (ROM) of the head and cause neck pain[6]. Therefore, many treatments are performed with the aim of restoring soft tissue function or mobility to the joints in patients with chronic neck pain. Joint mobilization (JM) and joint manipulation are the most widely used methods to increase mobility inside the joint capsule. These methods have been reported to increase the ROM and relieve pain[7, 8]. However, JM and joint manipulation performed at the end range of the ROM directly on the joints of the cervical vertebrae can cause tension in the patient�s neck muscles, because the cervical vertebrae are the most sensitive part of the spine and this tension protects the nerves and blood vessels[9].

 

The active release technique (ART) is a manual therapy for the recovery of soft tissue function that involves the removal of scar tissue, which can cause pain, stiffness, muscle weakness, and abnormal sensations including mechanical dysfunction in the muscles, myofascia, and soft tissue[10]. The effectiveness of ART has been reported for carpal tunnel syndrome, Achilles tendonitis, and tennis elbow, all of which involve soft tissue near joints in the distal parts of the body[11]. ART is also effective at reducing pain and increasing ROM in patients with a partial tear of the supraspinatus tendon[12]. Most patients with chronic neck pain experience pain and movement limitation as a result of soft tissue impairment in the neck[13]. Accordingly, more research on ART for the treatment of the soft tissues of the neck is warranted. However, no previous studies have assessed how ART can improve ROM in patients with neck pain.

 

Therefore, the purpose of this study was to compare the influence of ART and JM on the visual analog scale (VAS) score, pressure pain threshold (PPT), and neck ROM of patients with chronic neck pain, with the aim of elucidating additional information on their effects and identifying more efficient treatments that can be used in clinical settings.

 

Subjects and Methods

 

The study subjects were 24 patients admitted to Hospital A in Gangnamgu who had a 3-month or longer history of neck pain and had mild disability based on the Neck Disability Index (NDI; 5�14 points). The sample size of this study was based on that of Hyun[14], while considering the subject dropout rate, and accounting for significance level (5%), power of the test (0.8), and the effect size (f=0.7). Patients with structural abnormalities involving bone fracture or nerves those who had undergone surgery for hernia or had high blood pressure, spondyloarthritis, lumbar spinal stenosis, or scoliosis were excluded from the study. The participating patients understood the study purpose and associated information and provided their written consent to participation. This study was conducted using a procedure ethically suitable for human research in accordance with the Declaration of Helsinki.

 

We used the VAS to evaluate the degree of neck pain. The VAS is a subjective scoring method for recording the degree of present pain from 0 (no pain) to 10 (the most severe pain ever experienced) on a 10-cm scale. The VAS is difficult to compare among patients because of the subjective nature of the pain, but its reproducibility has been recognized in individual patients (ICC=0.97)[15].

 

The PPT measurement was performed by one investigator using an algometer. The right and left upper trapezius and sternocleidomastoideus (SCM) were pressed at a constant speed. The subject was asked to respond immediately when the pressure changed to pain, and the mechanical pressure was recorded. The mean value of two measurements was used; increasing PPT values indicate a higher-pressure pain threshold. An algometer is particularly useful for measuring the trigger point in myofacial pain syndrome, because it can determine the precise location of the source pain and quantify the pressure sensitivity of muscles (ICC=0.78�0.93)[16, 17].

 

Passive ROM was measured by fixing the subject�s shoulder so that it was not affected by the other parts of the trunk. Then, neck flexion, extension, right side bending, left side bending, right rotation, and left rotation were measured. The range of the angle was measured with a therapist passively assessing the patient�s pain-free neck-joint ROM[18].

 

The 24 subjects with chronic neck pain included in the study were randomly assigned to one of three groups following an equivalent control group pre-test/post-test design. For 3 weeks, the ART and JM groups received treatment twice per week for 20 minutes. After all the interventions were completed, the VAS score, PPT, and ROM were measured again. In the ART group, ART was used to treat the muscles demonstrating scar tissue, among the muscles involved in neck movement. After shortening based on fiber texture in the longitudinal direction, soft tissue mobilization was performed with active or passive stretching to lengthen the tissue that had been shortened[12].

 

JM was performed using Kaltenborn�s techniques of traction and gliding. In order to relieve pain with physiological movements including flexion, extension, side bending, and rotation, traction at Grade I or II was performed for 10 seconds. Additionally, in order to recover hypomobility, traction and gliding were performed at level 3 and maintained for 7 seconds. Both treatments included 2�3 seconds of rest and were repeated 10 times[19]. Subjects in the control group did not receive any treatment for chronic neck pain.

 

SPSS 18.0 for Windows was used to analyze the results. In order to confirm the homogeneity of subjects� general characteristics and dependent variables, descriptive statistics and the Kruskal-Wallis test were used. The Wilcoxon rank test was performed to assess the difference between pre- and post-treatment values in each group, and the Mann-Whitney U test was used to identify significant differences among the groups. The threshold for statistical significance was chosen as 0.05.

 

Results

 

The extent of change in VAS score, PPT, and ROM was compared between patients with chronic neck pain who underwent ART or JM. Twenty-four patients with a 3-month or longer history of chronic neck pain participated in this study. The three groups demonstrated no significant differences in NDI scores, ages, heights, or weights (p>0.05) (Table 1).

 

ART Table 1 | El Paso, TX Chiropractor

 

The ART and JM groups both demonstrated significant improvements in VAS pain scores (p<0.05), but no significant change was observed in the control group (p>0.05). The PPT significantly increased (p<0.05), in every muscle measured in the ART group, and in all muscles other than the right upper trapezius in the JM group. Muscle PPT demonstrated no significant change in the control group (p>0.05) (Table 2).

 

ART Table 2 | El Paso, TX Chiropractor

 

After treatment, the ART and JM groups both demonstrated significant increases (p<0.05) in every neck joint ROM parameter, while no significant changes were observed in the control group (p>0.05) (Table 2).

 

The extent of change in the VAS pain score and PPT between pre- and post-treatment significantly differed across the three groups (p<0.05). The posthoc test indicated that changes in the VAS scores significantly differed between the ART and control groups, and between the JM and control groups (p<0.05), but not between the ART and JM groups (p>0.05). The changes in PPTs of the right upper trapezius and left SCM significantly differed to between the ART and JM groups (p<0.05); however no significant differences were observed in the other muscles (p>0.05). Between the JM and control groups, the change in right SCM PPT demonstrated a significant difference (p<0.05); however, no difference was observed in other muscles (p>0.05). Between the ART and control group, the change in PPT significantly differed for all the measured muscles (p<0.05). The changes in VAS score and PPT were greater in the ART group than in the JM group, but these differences were not statistically significant (Table 3).

 

ART Table 3 | El Paso, TX Chiropractor

 

The extent of change in ROM after the treatments significantly differed across the three groups (p<0.05). The posthoc test indicated that the change in ROM significantly differed between the ART and JM groups only in neck flexion (p<0.05), but not in other ROM measurements (p>0.05). There was no significant difference in neck flexion ROM between the JM and control groups (p>0.05), but all other ROM parameters significantly differed between these groups (p<0.05). The ART and control groups significantly differed in terms of the change in ROM for all the parameters measured (p<0.05). The change in ROM was greater in the ART group than in the JM group, but this difference was not reach statistically significant (Table 3).

 

Dr-Jimenez_White-Coat_01.png

Dr. Alex Jimenez’s Insight

The following study compared the use of the active release technique (A.R.T.) to the use of joint mobilization to determine the best method for treating chronic neck pain symptoms. As it will be properly described below, the research study concluded that ART and joint mobilizations are both effective as treatment for patients with chronic neck pain, however, the active release technique demonstrated a greater effectiveness for neck pain associated with soft tissue injury. A.R.T. is believed to be a better treatment option for chronic neck pain mainly because soft tissue injuries are believed to be the cause of painful symptoms in 87.5 percent of cases, where ART is performed directly on the area of damage.

 

Discussion

 

Repetitive motions and the use of smart phones and tablets in abnormal head postures can stress the head, neck, and shoulder areas. Additionally, abnormal head posture can cause mechanical dysfunction of the cervical joint, which can lead to pain, fibrosis of soft tissue, adaptive shortening, loss of flexibility, and mechanical deformation reflecting the condition of hypomobility, where there is no movement inside the normal joint capsule[20, 21]. When mechanical dysfunction is present in a vertebra, manual therapy is typically performed, and it can be an effective method of relieving neck pain related to such dysfunction[22]. JM is used to treat joints with hypomobility or progressive limitation of mobility, by identifying a cervical segment with abnormal mobility and irritating the sensory receptors that sense pain, thus eliciting effects on the muscle, which in turn stimulate the muscles to apply force in the appropriate direction[8].

 

After 3 weeks of JM, the VAS, ROM, and PPT values of muscles other than the right upper trapezius demonstrated significant improvements compared to their pre-test values. The PPT also increased in the right upper trapezius, but the difference was not statistically significant. The trapezius is particularly susceptible to damage by repetitive movements of the hand and arm while performing work such as using a computer[23]. Most of the study participants were right-handed and thus performed more movement of the right upper extremity than the left, which may explain why the improvement of the right upper trapezius PPT was not reach statistically significant.

 

ART is a method for treating the soft tissues such as the tendon, nerve, and myofascia, and is performed for repetitive strain injury, acute injury, and functional fixation damage due to abnormal posture maintained over the long term. Furthermore, ART is an effective at resolving adhesion of scar tissue and the soft tissue that causes pain, spasm, muscle weakness, tingling, and other symptoms[11].

 

Robb et al.[24] demonstrated immediate improvement of muscle PPT when ART was used to treat patients with adductor strain. Additionally, in a study by Tak et al.[10], ART treatment for 3 weeks on the gluteus medius of a patient with low back pain for 3 weeks resulted in improvement of the patient�s VAS score and PPT. Although our target area differed from the studies of Tak et al.[10] and Robb et al.[24], significant improvement was observed in the VAS score, PPT, and ROM after using ART to treat the neck muscles in the present study. It is our opinion that these improvements in VAS score and PPT after treatment is the result of decreases in muscle tone after removing scar tissue adherent to soft tissue.

 

In a study by James[25] involving 20 young men with no injury of the lower extremity, hamstring flexibility increased immediately after ART was applied. Similarly, in the present study, ROM significantly increased after ART was applied on the neck for 3 weeks. This finding indicates that scar tissue, which can limit the mobility of soft tissue, can be removed by ART and thus relieve limitations of movement[12].

 

Although no statistically significant difference was detected in many cases, the change in the VAS score, PPT, and ROM demonstrated a consistent trend toward being greater in the ART group than in the JM group. This greater effect may be related to the observation that soft tissue injury is the cause of pain in 87.5% of neck pain cases, and ART is performed directly on the injured soft tissue[13], whereas JM treats the limited area of the joint. This study compared the effect of treatment over a short period of 3 weeks, and thus, it remains unclear how long its effectiveness is maintained. Longerterm follow-up surveys are needed after the cessation of treatment. Additionally, it is difficult to generalize our findings, as the sample sizes were small. In order to reinforce these findings, more research is needed.

 

In conclusion, this study compared the VAS score, PPT, and ROM across 24 subjects with chronic neck pain receiving ART, JM, or no treatment. It revealed that ART and JM both positively affected the VAS score, PPT, and ROM, and that the two methods demonstrated few significant differences in their effects. Thus, ART and JM are both effective for the treatment of patients with chronic neck pain, but ART demonstrated a trend toward greater effectiveness for patients with neck pain involving soft tissue injury. Therefore, ART appears to be a better option for treating patients with chronic neck pain in the clinical setting. Follow-up research involving greater numbers and diversity of subjects with longer terms are needed to expand upon these findings.

 

The purpose of the article above is to present the effectiveness of the active release technique, or ART, towards the management and improvement of chronic neck pain in a clinical setting. Information referenced from the National Center for Biotechnology Information (NCBI). The scope of our information is limited to chiropractic as well as to spinal injuries and conditions. To discuss the subject matter, please feel free to ask Dr. Jimenez or contact us at 915-850-0900 .

 

Curated by Dr. Alex Jimenez

 

Green-Call-Now-Button-24H-150x150-2-3.png

 

Additional Topics: Sciatica

Sciatica is medically referred to as a collection of symptoms, rather than a single injury and/or condition. Symptoms of sciatic nerve pain, or sciatica, can vary in frequency and intensity, however, it is most commonly described as a sudden, sharp (knife-like) or electrical pain that radiates from the low back down the buttocks, hips, thighs and legs into the foot. Other symptoms of sciatica may include, tingling or burning sensations, numbness and weakness along the length of the sciatic nerve. Sciatica most frequently affects individuals between the ages of 30 and 50 years. It may often develop as a result of the degeneration of the spine due to age, however, the compression and irritation of the sciatic nerve caused by a bulging or herniated disc, among other spinal health issues, may also cause sciatic nerve pain.

 

 

 

blog picture of cartoon paperboy big news

 

EXTRA IMPORTANT TOPIC: Chiropractor Sciatica Symptoms

 

 

MORE TOPICS: EXTRA EXTRA: El Paso Back Clinic | Back Pain Care & Treatments

Blank
References
1.�Chung SH, Her JG, Ko TS, et al. :�Effects of exercise on deep cervical flexors in patients with chronic neck pain.�J Phys Ther Sci, 2012,�24: 629�632.
2.�Hwangbo G:�Analysis of the change of the neck pressure pain threshold in long term computer users.�Int J Contents, 2008,�8: 151�158.
3.�Sarig-Bahat H:�Evidence for exercise therapy in mechanical neck disorders.�Man Ther, 2003,�8: 10�20.[PubMed]
4.�Hyung IH, Kim SS, Lee SY:�The effect of immediate pain and cervical ROM of cervical pain patients on stretching and manipulation.�J Korean Soc Phys Ther, 2009,�21: 1�7.
5.�Oh SG, Yu SH:�Biomechanical changes in lower quadrant after manipulation of low back pain patients with sacroiliac joint dysfunction.�J Korean Soc Phys Ther, 2001,�8: 167�180.
6.�Jull GA, Falla D, Vicenzino B, et al. :�The effect of therapeutic exercise on activation of the deep cervical flexor muscles in people with chronic neck pain.�Man Ther, 2009,�14: 696�701.�[PubMed]
7.�Ko TS, Jeong UC, Lee KW:�Effects of the inclusion thoracic mobilization into cranio-cervical flexor exercise in patients with chronic neck pain.�J Phys Ther Sci, 2010,�22: 87�91.
8.�Kim DD:�The effects of manipulation and mobilization on NDI and CROM in young adults with mild neck disability.�J Korean Acad Orthop Man Phys Ther, 2010,�16: 53�60.
9.�Jun YW: The effects of upper thoracic joint mobilization technique using Kaltenborn-Evjenth concept on cervicothoracic ROM and pain in patients with chronic neck pain. Graduate school Korea University Master�s Degree, 2012.
10.�Tak SJ, Lee YW, Choi W, et al. :�The effects of active release technique on the gluteus mediusfor pain relief in persons with chronic low back pain.�Physical Therapy Rehabilitation Science, 2013,�2: 27�30.
11.�Brian A, Kamali A, Michael Leahy P: Release Your Pain: Resolving Repetitive Strain Injuries with Active Release Techniques. Pub Group West, 2005, 15�29.
12.�Lee SJ, Park JH, Nam SH, et al. :�Two clinical cases of active release technique with Korean medicine treatment for supraspinatus tendon partial tear.�J CHUNA Man Med Spine Nerves, 2014,�9: 89�101.
13.�Dvord J, Valach L, Schmdt S:�Cervical spine injuries in Swizerland.�Man Med, 1989,�4: 7�16.
14.�Hyun SW: The effects of joint mobilization and conservative physical therapy on the range of motion and pain in patients with cervical pain. Graduate school Kookmin University Master�s Degree, 2003.
15.�Bijur PE, Silver W, Gallagher EJ:�Reliability of the visual analog scale for measurement of acute pain.�Acad Emerg Med, 2001,�8: 1153�1157.�[PubMed]
16.�Kim SH, Kwon BA, Lee WH:�Effects of cervical spinal stabilization training in private security on chronic neck pain and cervical function, neck pain, ROM.�Korean Secur Sci Rev, 2010,�25: 89�107.
17.�Cho SH: The effect of myofascial release technique and forward head posture correction exercise on chronic tension-type headache. Graduate school Catholic University of Pusan Doctor�s Degree, 2014.
18.�Jang HJ: Effects of combined exercise program on pain and function and range of motion and fatigability in chronic neck pain. Graduate school University Sahmyook Master�s Degree, 2011.
19.�Kim HJ, Bae SS, Jang C:�The effects of joint mobilization on neck pain.�J Korean Soc Phys Ther, 2003,15: 65�90.
20.�C�t� P, Cassidy JD, Carroll LJ, et al. :�The annual incidence and course of neck pain in the general population: a population-based cohort study.�Pain, 2004,�112: 267�273.�[PubMed]
21.�Lee JH, Lee YH, Kim HS, et al. :�The effects of cervical mobilization combined with thoracic mobilization on forward head posture of neck pain patients.�J Phys Ther Sci, 2013,�25: 7�9.
22.�Ferreira LA, Santos LC, Pereira WM, et al. :�Analysis of thoracic spine thrust manipulation for reducing neck pain.�J Phys Ther Sci, 2013,�25: 325�329.
23.�Seo HK: The effect of myofascial release, joint mobilization, and Mckenzine on the cervical muscle activity. Graduate school Daegu University Doctor�s Degree, 2008.
24.�Robb A, Pajaczkowski J:�Immediate effect on pain thresholds using active release technique on adductor strains: pilot study.�J Bodyw Mov Ther, 2011,�15: 57�62.�[PubMed]
25.�George JW, Tunstall AC, Tepe RE, et al. :�The effects of active release technique on hamstring flexibility: a pilot study.�J Manipulative Physiol Ther, 2006,�29: 224�227.�[PubMed]
Close Accordion
Common Causes of Neck and Back Pain in El Paso, TX

Common Causes of Neck and Back Pain in El Paso, TX

Technology makes life more convenient, but it has also made our lifestyles more sedentary. Poor posture’s stress places unnecessary amounts of pressure and tension in the neck and back. We know neck pain and back pain can be debilitating, especially after years of improper posture and a sedentary lifestyle. Chiropractic care can help reduce pain and discomfort from the spine with spinal adjustments and manual manipulations, as well as several lifestyle modifications. Chiropractic can help treat a variety of injuries and conditions affecting spine health. Before further discussing what chiropractic care can do for you, we’ll first discuss the common causes of neck and back pain.

 

Back Pain

 

Back pain is common, but it doesn’t have to be permanent. Whether your pain has been brought on by years of heavy lifting or a single mishap or fall, a doctor of chiropractic, or chiropractor, will do their very best to discover which type of treatment method will guarantee you relief from your symptoms. Strengthening exercises help to train your heart to support your weight and spinal adjustments and manual manipulations are ways to relieve inflammation, reduce pressure and restore the proper alignment of the spine to decrease pain and discomfort. Pain relief methods will address your symptoms, but chiropractic care can promote recovery for long term spine pain relief.

 

Neck Pain

 

If you experience pain or discomfort in your neck, you may want to address the symptoms with safe and effective alternative treatment options. While the solutions that may assist with your pain are determined by the underlying cause of the distress, a chiropractor can properly diagnose the source of the symptoms, identifying the causes and giving a personalized treatment plan to assist with the situation. Chiropractic care can also provide treatment for a variety of issues causing symptoms of neck pain.

 

What Causes Pain?

 

Pain stems from a number of situations and problems. It may relate trauma from an injury or due to an aggravated condition along the length of the spine or it may even relate to posture and the way you sleep during the night. Depending on the origin of the pain and the regions affected by the discomfort, the specific treatments may vary.�Common reasons for your pain include:

 

  • A sedentary lifestyle or having a computer on your office, which causes long intervals of holding your head in the same place
  • Looking down in a tablet, computer, telephone or other device for extended periods
  • Whiplash or injuries to your neck and back in an automobile accident
  • A herniated disc in the neck or back
  • Injuries to the spine
  • Poor posture
  • Stress on several regions of the spine, or compression
  • Certain diseases or conditions, like degenerative disc disease or arthritis

 

5 Causes of Neck and Back Pain or Discomfort

 

If you have suffered from pain or discomfort in your neck or back, you may very well be aware of how debilitating the symptoms can become. We are able to complete all of our daily activities and tasks on a regular basis because the spine offers rigidity, stability, and endurance at the same exact time. Through the structure and function of the ligaments, tendons, intervertebral discs and facet joints, the mechanical connection that your body needs is provided by the spine. Just like any sort of apparatus, breakdowns can happen at any time, resulting in symptoms of neck and back pain or discomfort. Next, we will discuss the five common causes of neck and back pain.

 

Disc Herniation

 

Disc herniation is among the most frequent causes of neck and back pain. It goes by several names like a pinched nerve, and bulging or burning disc, but regardless of what you call it, it can be intense and long-lasting. Pain in the legs, also called sciatica, is often the first indication of a herniated disc in the lumbar spine, or low back. Since 90 percent of herniated discs occur within this region, leg pain is the most frequent symptom. Other signs may include severe pain, weakness and tingling sensations down one of both legs. Chiropractic care, physical therapy and gentle stretches and exercises are the most common kinds of treatment for a herniated disc. These conservative treatments can cut the need for more aggressive interventions and can be remarkably powerful. For surgical procedures, it might be considered in scenarios where non-operative remedies are ineffective.

 

Spinal Stenosis

 

Spinal stenosis is defined as an abnormal narrowing of the bony channel which contains the spinal cord or the spinal nerves. Unlike other spinal problems, spinal stenosis tends to come on slowly and gradually gets worse. Spinal stenosis is treated with a combination of gentle exercises and lifestyle modifications. You will see that some symptoms of spinal stenosis can be relieved by sitting or lying down, maintaining a proper posture, or preventing certain activities that cause the stenosis symptoms. In acute cases, spinal epidural shots may be used to deal with the pain and alleviate discomfort. Chiropractic care can also be used to treat spinal stenosis symptoms.

 

Spinal Stenosis Diagram | El Paso, TX Chiropractor

 

Sprains and Strains

 

When you have a sudden onset of pain or discomfort in your neck or back, the problem could be a sprain or strain. Moving the wrong way, overdoing an exercise regime, or decreasing physical activity frequency can lead to a sprain or strain. The good news is that if the time and appropriate treatment are performed, the pain and distress usually go away in a determined amount of time. It’s ideal to see a healthcare professional in case you’ve suffered a sprain or strain to your neck or back. Do not let what you believe is a small sprain or strain turn out to be a bigger issue. Healthcare professionals recommend rest and limited activity until you are feeling better if the issue is a sprain or strain. You may benefit from physical therapy and exercise like water aerobics and stretching exercises to help you heal and recover faster.

 

Spinal Osteoarthritis

 

Spinal osteoarthritis is� defined as the breakdown of cartilage in discs or the joints in the neck or back. In some cases, it can cause bone wane causing painful pressure on the nerves going into the spine. If diagnosed with spinal osteoarthritis, you may receive conservative or very aggressive treatment depending on the issue; for example, rest and hot or cold packs or specific medications. However, chiropractic care may be a safe and effective alternative treatment option for some people with spinal osteoarthritis. It’s essential to first talk to a qualified and experienced healthcare professional regarding the recommended treatment for you. If unsuccessful, surgery may be needed, which is usually recommended only as a last resort for patients with spinal osteoarthritis.

 

Vertebral Compression Fracture

 

A vertebral compression fracture can be a serious condition that creates pain in the neck or back, depending on where the fracture occurs. Vertebral compression fractures occur as a result of tiny cracks from the vertebrae; the bones of the spine. As time passes, hairline fractures may cause the vertebrae to collapse, which is what is known as a spinal or vertebral compression fracture. The symptoms of a compression fracture can be acute and sudden back pain during a change of posture or movement. Rather than standing tall, you might see that you have a stooped appearance. This sign should not be ignored by you; as with any medical illness, early intervention may often make it much easier to deal with.

 

There are several choices for treating your vertebral compression fracture, which can include some types of drugs and/or medications to temporarily relieve symptoms while ongoing with treatment. Other treatment choices are bracing of the neck, physical activity or exercise that is limited and bed rest. Understanding the causes of neck and back pain can offer you a head start on receiving the appropriate treatment option for your specific spine health issue. If you suffer from any type of pain or discomfort, please contact a healthcare professional who specializes in the diagnosis, treatment and prevention of spinal health issues, such as a chiropractor.

 

How Can a Chiropractor Help?

 

When you find chiropractic care for neck and back pain, they will first diagnose the source of your symptoms, utilizing the appropriate diagnostic tools to find out the underlying causes of the distress. Chiropractors supply treatments after determining the reasons to address the factors. A chiropractor helps with pain relief by correcting the compression or inadequate alignment on your own neck and back. When your spine is misaligned or subluxated, it can lead to a variety of spinal health issues, such as the ones mentioned above. Injuries and/or conditions which are left untreated for an extended period of time may worsen without proper treatment.

 

Chiropractic care utilizes spinal adjustments and manual manipulations to reduce the pressure in your spine and improve the alignment of the neck and back, in order to restore the original integrity of your spine. A doctor of chiropractic, or doctor will concentrate on helping your body heal and recuperate through natural solutions. They might also recommend nutritional advice and exercises, in addition to stretches to assist with the healing procedure. Chiropractors may additionally create a personalized treatment program based on the possible complications associated with the injuries on your own neck and back as well as the reason for your pain and discomfort.

 

Dr-Jimenez_White-Coat_01.png

Dr. Alex Jimenez’s Insight

Neck and back pain or discomfort are some of the most common types of issues frequently treated by a chiropractor. Although neck and back pain can be caused by a wide variety of spinal health problems, chiropractic care is a safe and effective, alternative treatment option that can help ease the symptoms associated with many injuries and/or conditions related to the musculoskeletal and nervous system. As an experienced chiropractor, spinal adjustment and manual manipulations can help reduce painful symptoms by allowing the body to naturally heal itself, restoring the quality of life of patients.

 

When to Seek Chiropractic Therapy

 

Seeking chiropractic treatment for pain and discomfort is a personal decision, nevertheless, you should consider treatment immediately after a car accident or some other type of injury or aggravated condition. We advise seeking treatment for persistent and chronic issues. You might want to consider chiropractic care if you notice symptoms due to using electronics throughout the day or sitting at your work, since it may worsen over time if left untreated, even if it is simply a slight soreness in your muscles.

 

Treating pain and discomfort in your body starts with improving the health and wellness of your spine. To learn more about addressing problems on your neck and spine or to set an appointment with a chiropractor, please make sure to talk to your primary care provider or healthcare professional. The scope of our information is limited to chiropractic as well as to spinal injuries and conditions. To discuss the subject matter, please feel free to ask Dr. Jimenez or contact us at 915-850-0900 .

 

Curated by Dr. Alex Jimenez

 

Green-Call-Now-Button-24H-150x150-2-3.png

 

Additional Topics: Back Pain

 

According to statistics, approximately 80% of people will experience symptoms of back pain at least once throughout their lifetimes. Back pain is a common complaint which can result due to a variety of injuries and/or conditions. Often times, the natural degeneration of the spine with age can cause back pain. Herniated discs occur when the soft, gel-like center of an intervertebral disc pushes through a tear in its surrounding, outer ring of cartilage, compressing and irritating the nerve roots. Disc herniations most commonly occur along the lower back, or lumbar spine, but they may also occur along the cervical spine, or neck. The impingement of the nerves found in the low back due to injury and/or an aggravated condition can lead to symptoms of sciatica.

 

blog picture of cartoon paperboy big news

 

EXTRA IMPORTANT TOPIC:�Back Pain Chiropractic Care

 

MORE TOPICS: EXTRA EXTRA: El Paso Back Clinic | Back Pain Care & Treatments

Whiplash Treatment Guidelines in El Paso, TX

Whiplash Treatment Guidelines in El Paso, TX

Whiplash is one of the most prevalent types of injuries resulting from an automobile accident, most commonly during rear-end auto collisions. However, whiplash-associated disorders can develop due to a variety of other circumstances, including sports injuries, amusement park rides or physical abuse. Whiplash occurs when the soft tissues of the neck, such as the muscles, tendons and ligaments, extend beyond their natural range of motion because of a sudden back-and-forth movement of the head. Furthermore, the sheer force of an impact can stretch and even tear the complex structures surrounding the cervical spine.

 

The symptoms of whiplash-associated disorders may take days, weeks or even months to manifest, which is why it’s important for individuals who’ve been involved in an automobile accident to seek immediate medical attention. There are many different types of treatment options which can safely and effectively help treat whiplash. The purpose of the following article is to demonstrate the treatment guidelines of neck pain-associated disorders and whiplash-associated disorders.

 

The Treatment of Neck Pain-Associated Disorders and Whiplash-Associated Disorders: A Clinical Practice Guideline

 

Abstract

 

  • Objective: The objective was to develop a clinical practice guideline on the management of neck pain�associated disorders (NADs) and whiplash-associated disorders (WADs). This guideline replaces 2 prior chiropractic guidelines on NADs and WADs.
  • Methods: Pertinent systematic reviews on 6 topic areas (education, multimodal care, exercise, work disability, manual therapy, passive modalities) were assessed using A Measurement Tool to Assess Systematic Reviews (AMSTAR) and data extracted from admissible randomized controlled trials. We incorporated risk of bias scores in the Grading of Recommendations Assessment, Development, and Evaluation. Evidence profiles were used to summarize judgments of the evidence quality, detail relative and absolute effects, and link recommendations to the supporting evidence. The guideline panel considered the balance of desirable and undesirable consequences. Consensus was achieved using a modified Delphi. The guideline was peer reviewed by a 10-member multidisciplinary (medical and chiropractic) external committee.
  • Results: For recent-onset (0-3 months) neck pain, we suggest offering multimodal care; manipulation or mobilization; range-of-motion home exercise, or multimodal manual therapy (for grades I-II NAD); supervised graded strengthening exercise (grade III NAD); and multimodal care (grade III WAD). For persistent (N3 months) neck pain, we suggest offering multimodal care or stress self-management; manipulation with soft tissue therapy; high-dose massage; supervised group exercise; supervised yoga; supervised strengthening exercises or home exercises (grades I-II NAD); multimodal care or practitioner�s advice (grades I-III NAD); and supervised exercise with advice or advice alone (grades I-II WAD). For workers with persistent neck and shoulder pain, evidence supports mixed supervised and unsupervised high-intensity strength training or advice alone (grades I-III NAD).
  • Conclusions: A multimodal approach including manual therapy, self-management advice, and exercise is an effective treatment strategy for both recent-onset and persistent neck pain. (J Manipulative Physiol Ther 2016;39:523-44.e20) Key
  • Indexing Terms: Practice Guideline; Neck Pain; Whiplash Injuries; Chiropractic; Therapeutic Intervention; Disease Management; Musculoskeletal Disorders

 

Dr. Alex Jimenez’s Insight

Whiplash occurs when the sheer force of an impact causes the head and neck to jolt abruptly back-and-forth in any direction, stretching the complex structures surrounding the cervical spine beyond their normal range. Neck pain, headache and radiating pain resulting from whiplash are common complaints frequently reported by individuals after being involved in an automobile accident. However, whiplash can also result from a variety of other circumstances. Whiplash-associated disorders are a prevalent source of disability and a common reason many auto accident victims seek medical attention from chiropractors, physical therapists and primary care physicians. Fortunately, many treatment guidelines exist to safely and effectively improve as well as manage the symptoms of whiplash. Chiropractic care is a well-known alternative treatment option for whiplash-associated disorders. Spinal adjustments and manual manipulations can safely and effectively restore the original alignment of the spine, reducing symptoms and alleviating whiplash complications.

 

Introduction

 

Neck pain and its associated disorders (NAD), including headache and radiating pain into the arm and upper back, are common and result in significant social, psychological, and economic burden.1-4 Neck pain, whether attributed to work, injury, or other activities,5 is a prevalent source of disability and a common reason for consulting primary health care providers, including chiropractors, physical therapists, and primary care physicians.6 The estimated annual incidence of neck pain measured in 4 studies ranged between 10.4% and 21.3%, with a higher incidence noted in office and computer workers.7 Although some studies report that between 33% and 65% of people have recovered from an episode of neck pain at 1 year, most cases follow an episodic course over a person�s lifetime, and thus, relapses are common.7 Neck pain is a leading cause of morbidity and chronic disability worldwide.5,8 In 2008 the Bone and Joint Decade Task Force on Neck Pain and Its Associated Disorders reported that 50% to 75% of individuals with neck pain also report pain 1 to 5 years later.4 Several modifiable and nonmodifiable environmental and personal factors influence the course of neck pain, including age, previous neck injury, high pain intensity, self-perceived poor general health, and fear avoidance.7

 

Neck pain related to whiplash-associated disorders (WADs) most commonly results from motor vehicle accidents.9,10�Whiplash-associated disorders disrupt the daily lives of adults around the world and are associated with considerable pain, suffering, disability, and costs.3,11 Whiplash-associated disorders are defined as an injury to the neck that occurs with sudden acceleration or deceler- ation of the head and neck relative to other parts of the body, typically occurring during motor vehicle collisions.10,12 The majority of adults with traffic injuries report pain in the neck and upper limb pain. Other common symptoms of WADs include headache, stiffness, shoulder and back pain, numbness, dizziness, sleeping difficulties, fatigue, and cognitive deficits.9,10 The global yearly incidence rate of emergency department visits as a result of acute whiplash injuries after road traffic crashes is between 235 and 300 per 100,000.3,13,14 In 2010, there were 3.9 million nonfatal traffic injuries in the United States.11 The economic costs of motor vehicle crashes that year totaled USD$242 billion, including $23.4 billion in medical costs and $77.4 billion in lost productivity (both market and household).11 In Ontario, traffic collisions are a leading cause of disability and health care use and�expenditures, resulting in the automobile insurance system paying nearly CND$4.5 billion in accident benefits in 2010.15

 

Diagram showing the process of whiplash resulting from an automobile accident.

 

More than 85% of patients experience neck pain after a motor vehicle accident, often associated with sprains and strains to the back and extremities, headache, psychological symptomatology, and mild traumatic brain injury.10 Whiplash injuries have an effect on general health, with recovery in the short term reported by 29% to 40% of individuals with WAD in Western countries that have compensation schemes for whiplash injuries. 16,17 The median time to first reported recovery is estimated at 101 days (95% confidence interval: 99-104) and about 23% are still not recovered after 1 year.13

 

Image displaying X-rays before and after whiplash.

 

Image demonstrating an X-ray of the neck during flexion and extension.

 

 

The 2000-2010 Bone and Joint Decade Task Force on Neck Pain and its Associated Disorders recommended that all types of neck pain, including WADs,18 be included under the classification of NAD.19 NAD can be classified into 4 grades, distinguished by the severity of symptoms, signs, and impact on activities of daily life (Table 1).

 

The clinical management of musculoskeletal disorders, and neck pain in particular, can be complex and often involves combining multiple interventions (multimodal care) to address its symptoms and consequences.19�In this guideline, multimodal care refers to treatment involving at least 2 distinct therapeutic methods, provided by 1 or more health care disciplines.20 Manual therapy (including spinal manipulation), medication, and home exercise with advice are commonly used multimodal treatments for recent- onset and persistent neck pain.21,22 Thus, there is a need to determine which treatments or combinations of treatments are more effective for managing NAD and WAD.

 

Rationale for Developing This Guideline

 

The Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration20 recently updated the systematic reviews from the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders (Neck Pain Task Force).23 Consequently, it was deemed timely to update the recommendations of 2 chiropractic guidelines on NAD (2014)24 and WAD (2010)25 produced by the Canadian Chiropractic Association and the Canadian Federation of Chiropractic Regulatory and Educational Accrediting Boards (the �Federation�) into a single guideline.

 

Table 1 Classification of Neck Pain-Associated Disorders and Whiplash-Associated Disorders

 

Scope and Purpose

 

The aim of this clinical practice guideline (CPG) was to synthesize and disseminate the best available evidence on the management of adults and elderly patients with recent onset (0-3 months) and persistent (N3 months) neck pain and its associated disorders, with the goal of improving clinical decision making and the delivery of care for patients with NAD and WAD grades I to III. Guidelines are �Statements that include recommendations intended to optimize patient care that are informed by a systematic review of evidence and an assessment of the benefits and harms of alternative care options.�26

 

The target users of this guideline are chiropractors and other primary care health care providers delivering conservative care to patients with NADs and WADs, as well as policymakers. We define conservative care as treatment designed to avoid invasive medical therapeutic measures or operative procedures.

 

OPTIMa published a closely related guideline in the European Spine Journal.27 Although we reached similar results, OPTIMa developed recommendations using the modified Ontario Health Technology Advisory Committee (OHTAC) framework.28 In contrast, our guideline used the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach. GRADE provides a common, sensible, and transparent approach to grading quality (or certainty) of evidence and strength of recom- mendations (http://www.gradeworkinggroup.org). GRADE was the highest scoring instrument among 60 evidence grading systems29 and has been determined to be reproducible among trained raters.30 GRADE is now considered a standard in guideline development and has been adopted by many international guideline organizations and journals.31 The Canadian Chiropractic Guideline Initiative (CCGI) guideline panel considered available high-quality systematic reviews, updated the search of the peer-reviewed published reports up to December 2015, and then used the GRADE approach to formulate recommen- dations for the management of neck pain and associated disorders.

 

Framework

 

To inform its work, the CCGI considered recent advances in methods to conduct knowledge synthesis,32 derive evidence-based recommendations, 31,33 adapt high- quality guidelines, 34 and develop 35 and increase the uptake of CPGs.36,37 An overview of CCGI structure and methods is provided in Appendix 1.

 

Methods

 

Ethics

 

Because no novel human participant intervention was required and secondary analyses were considered, the research presented in this guideline is exempt from institutional ethics review board approval.

 

Selection of Guideline Development Panelists

 

The CCGI project lead (A.B.) appointed 2 co-chairs (J.O. and G.S.) for the guideline development group and nominated the project executive committee and the remaining guideline panelists. J.O. served as the lead methodologist on the guideline panel. G.S. helped ensure geographic representation of the panel and advised on specific duties of panel members, time commitment, and decision-making process for reaching consensus (develop- ment of key questions and of recommendations). To ensure a broad representation, the guideline panel included clinicians (P.D., J.W.), clinician researchers (F.A., M.D., C.H., S.P., I.P., J.S.) methodologists (J.O., A.B., M.S., J.H.), a professional leader/decision maker (G.S.), and 1 patient advocate (B.H.) to ensure that patient values and preferences were considered. One observer (J.R.) moni- tored the 3 face-to-face meetings of the guideline panel held in Toronto (June and September 2015 and April 2016).

 

All CCGI members, including guideline panelists and peer reviewers, were required to disclose any potential conflict of interest by topic before participation and during the guideline development process. There was no self- declaration of conflicts of interest among the panel or the reviewers.

 

Key Question Development

 

Six topic areas (exercise, multimodal care, education, work disability, manual therapy, passive modalities) on the conservative management of NAD and WAD grades I to III were covered in 5 recent systematic reviews by the OPTIMa Collaboration,38-42 among a total of 40 reviews on the management of musculoskeletal disorders.20 The panel met over 2 days in June 2015 to brainstorm about potential key questions.

 

Table 2 Topics and Key Questions Addressed by the Guideline Development Group

 

Table 2 Continued

 

Table 2 Continued (last)

 

Search Update and Study Selection

 

The panel assessed the quality of eligible systematic reviews using the AMSTAR tool43 and its 11 criteria (http://amstar.ca/Amstar_Checklist.php).

 

Because the last search dates of included systematic reviews were 2012,40,41 2013,38,39,42 and 2014,42 the panel updated the literature searches in Medline and Cochrane Central databases on December 24, 2015 using the published search strategies. We used a 2-phase screening process to select additional eligible studies. In phase 1, 2 independent reviewers screened titles and abstracts to determine the relevance and eligibility of studies. In phase 2, the same pairs of independent reviewers screened full-text articles to make a final determination of eligibility. Reviewers met to resolve disagreements and reach consensus on the eligibility of studies in both phases, with arbitration by a third reviewer if needed. Studies were included if they1 met the PICO (population, intervention, comparator, outcome) criteria and2 were randomized controlled trials (RCTs) with an inception cohort of at least 30 participants per treatment arm with the specified condition, because this sample size is considered the minimum needed for non-normal distributions to approx- imate the normal distribution.44

 

Data Abstraction and Quality Assessment

 

Data were extracted from the included studies identified in each systematic review, including study design, participants, intervention, control, outcomes, and funding.

 

The internal validity of included studies was assessed by the OPTIMa collaboration using the Scottish Intercollegiate Guidelines Network (SIGN) criteria.45

 

For articles retrieved from the updated search, pairs of independent reviewers critically appraised the internal validity of eligible studies using the SIGN criteria,46 similar to the OPTIMa collaboration reviews. Reviewers reached consensus through discussion. A third reviewer was used to resolve disagreements if consensus could not be reached. A quantitative score or a cutoff point to determine the internal validity of studies was not used. Instead, the SIGN criteria were used to assist reviewers in making an informed overall judgment on the risk of bias of included studies. 47

 

Synthesis of Results

 

J.O. extracted data from scientifically admissible studies into evidence tables. A second reviewer (A.B.) indepen- dently checked the extracted data. We performed a qualitative synthesis of findings and stratified results based on the type and duration of the disorder (ie, recent [symptoms lasting b3 months] vs persistent [symptoms lasting N3 months]).

 

Recommendation Development

 

We used the Guideline Development Tool (http:// www.guidelinedevelopment.org), and assessed the quality of the body of evidence for our outcomes of interest by�applying the GRADE approach.48 We used the evidence profiles to summarize the evidence.49 The quality of evidence rating (high, moderate, low, or very low) reflects our confidence in the estimate of the effect to support a recommendation and considers the strengths and limitations of the body of evidence stemming from risk of bias, imprecision, inconsistency, indirectness of results, and publication bias.50 Assessment of quality of evidence was carried out in the context of its relevance to the primary care setting.

 

Figure 1 PRISMA Flow Diagram

 

Using the Evidence to Decisions (EtD) Framework (http://www.decide-collaboration.eu/etd-evidence- decision-framework), the panel formally met in September 2015 and April 2016 to consider the balance of desirable and undesirable consequences to determine the strength of each recommendation, using informed judgment on the quality of evidence and effect sizes, resource use, equity, acceptability, and feasibility. To make a recommendation, the panel needed to express an average judgment that was beyond neutral with respect to the balance between desirable and undesirable consequences of an intervention, as outlined in the EtD. We defined the strength rating of a recommendation (strong or weak) as the extent to which the desirable consequences of an intervention outweigh its undesirable consequences. A strong recommendation can be made when the desirable consequences clearly outweigh the undesirable consequences. In contrast, a weak recommendation is made when, on the balance of probabilities, the desirable consequences likely outweigh the undesirable consequences. 49,51

 

Figure 2 PRISMA Flow Diagram

 

The panel provided recommendations based on the evidence if statistically and clinically significant differ- ences were found. The panel followed a 2-step process in making a recommendation. We first agreed that there should be evidence of clinically meaningful changes occurring over time in the study population and that a single consensus threshold of clinical effectiveness should be applied consistently. We reached a consensus decision that a 20% change in the outcome of interest within any study group was required to make a recommendation. The decision to use a 20% threshold was informed by current published reports and relevant available minimal clinically important differences (MCIDs).52-55

 

However, MCIDs can vary across populations, settings, and conditions and depending on whether within-group or between-group differences are being assessed. Therefore, the panel considered MCID values for the most relevant outcomes (ie, 10% for visual analog scale [VAS] or Neck Disability Index [NDI; 5/50 on the NDI], 20% for numerical rating scale [NRS]) and chose the more conservative of these values as the threshold when evaluating between group differences.52,54

 

Second, the results from relevant studies were used to formulate a recommendation where appropriate. A treat- ment determined to be effective (with statistically significant differences between baseline and follow-up scores and�clinical significance based on the MCID applied in the study) was recommended by our panel. If a study found 2 or more treatments to be equally effective based on our threshold, then the panel recommended all equivalently effective treatments.

 

Figure 3 PRISMA Flow Diagram

 

The EtD Frameworks were completed and recommen- dations were drafted over a series of conference calls with panel members after making judgments about 4 decision domains: quality of evidence (confidence in estimates of effect); balance of desirable (eg, reduced pain and disability) and undesirable outcomes (eg, adverse reactions); confidence about the values and preferences for the target population; and resource implications (costs).56,57 A synthe- sis of our judgments about the domains determined the direction (ie, for or against a management approach) and the strength of recommendations (the extent to which one can be confident that the desirable conse- quences of an intervention outweigh the undesirable consequences). A specific format was followed to formulate recommendations using patient description and the treatment comparator.56 Remarks were added for clarification if needed. If the desirable and undesirable consequences were judged to be evenly balanced and the evidence was not compelling, the panel decided not to write any recommendation.

 

A modified Delphi technique was used at an in-person meeting to achieve consensus on each recommendation.58 Using an online tool (www.polleverywhere.com), panelists�voted their level of agreement with each recommendation (including quality of evidence and strength of recom- mendation) based on a 3-point scale (yes, no, neutral). Before voting, panelists were encouraged to discuss and provide feedback on each recommendation in terms of suggested wording edits or general remarks. To achieve consensus and be included in the final manuscript, each recommendation had to have at least 80% agreement with a response rate of at least 75% of eligible panel members. All recommendations achieved consensus in the first round.

 

Figure 4 PRISMA Flow Diagram

 

Peer Review

 

A 10-member external committee composed of stake- holders, end-users, and researchers from Canada, the United States, and Lebanon (Appendix 2) independently reviewed the draft manuscript, recommendations, and supporting evidence. The AGREE II instrument was used to assess the methodological quality of the guideline.35 Feedback received was collected and considered in a revised draft for a second round of review. Chairs of the guideline panel provided a detailed response to reviewers� comments. For a glossary of terms, please see Appendix 3.

 

Figure 5 PRISMA Flow Diagram

 

Results

 

Key Question Development

 

Thirty-two standardized key questions were developed in line with the PICO (population, intervention, comparator, outcome) format. The panel recognized overlap in content and relevance among some key questions. After combining 3 questions, we ultimately addressed a total of 29 key questions (Table 2).

 

Study Selection and Quality Assessment: OPTIMa Reviews

 

OPTIMa searches yield 26 335 articles screened.38-42 After removal of duplicates and screening, 26 273 articles did not meet selection criteria, leaving 109 articles eligible for critical appraisal. Fifty-nine studies (62 articles) published from 2007 to 2013 were deemed scientifically admissible and included in the synthesis (Appendix 4). Each review used was rated as either moderate or high quality (AMSTAR score 8-11).59

 

Search Update and Study Selection

 

Our updated search yielded 7784 articles. We removed 1411 duplicates and screened 6373 articles for eligibility (Figs. 1-5). After screening, 6321 articles did not meet our selection criteria (phase 1), leaving 52 articles for full-text review (phase 2) and critical appraisal (studies on the topic of multimodal care (n = 12), structured patient education (n = 3),�exercise (n = 8), work disability interventions (n = 13), manual therapy (n = 4), soft tissues (n = 2), and passive modalities (n = 6). Of the 52 RCTs, 4 scientifically admissible studies were included in our synthesis. The remaining articles failed to address the key question (n = 1); selected population (n = 2), outcomes (n = 13), or intervention (n = 11); had no between estimates (n = 19); or were duplicates (n = 1) or a secondary analysis of an included study (n = 1) (Appendix 5).

 

Table 3 Neck Manipulation vs Neck Mobilization

 

Table 4 Multimodal Care vs Home Exercises vs Medication

 

Table 5 Strengthening Exercises vs Advice

 

Quality Assessment and Synthesis of Results

 

The GRADE evidence profile and risk of bias within included studies are presented in Tables 3-15 and Appendix 6, respectively.

 

Recommendations

 

We present recommendations as follows:

  • Recent-onset (0-3 months) grades I to III NAD
  • Recent-onset (0-3 months) grades I to III WAD
  • Persistent (N3 months) grades I to III NAD
  • Persistent (N3 months) grades I to III WAD

 

Recommendations for Recent-Onset (0-3 Months) Grades I to III NAD

 

Manual Therapy

 

Key Question 1: Should neck manipulation vs neck mobilization be used for recent-onset (0-3 months) grades I to II NAD?

 

Summary of Evidence. One RCT by Leaver et al. 60 evaluated the effectiveness of neck manipulation or neck mobilization delivered by physiotherapists, chiropractors, or osteopaths for recent-onset grades I to II neck pain (?2 NRS). All patients received advice, reassurance, or a continued exercise program as indicated for 4 treatments over 2 weeks unless recovery was achieved or a serious adverse event occurred. There was no statistically significant difference in Kaplan-Meier recovery curves between groups for recovery from neck pain and recovery of normal activity, and no statistically significant differences between groups for pain, disability, or other outcomes (function, global perceived effect, or health-related quality of life) at any follow-up point (Table 3).

 

One other RCT by Dunning et al.61 evaluated the effectiveness of a single high-velocity, low-amplitude (thrust) manipulation (n = 56) directed to the upper cervical spine (C1-C2) and upper thoracic spine (T1-T2) compared with a (nonthrust) mobilization (n = 51) directed to the same anatomical regions for 30 seconds for patients with neck pain. Findings indicated a greater reduction in pain (NPRS) and disability (NDI) in the thrust manipulation group compared with the mobilization at 48 hours. No serious adverse events were reported. Minor adverse events were not collected. This study did not inform our recommendation because1 patient complaints were not recent onset (mean�duration N337 days in both groups), and2 outcomes were measured at 48 hours only. The Guideline Development Group (GDG) considered this an important study limitation because one cannot assume these benefits would have carried on for a longer period. The panel acknowledged, however, that some patients may value obtaining fast pain relief even if temporary.

 

The panel determined that the overall certainty in the evidence was low, with large desirable relative to undesirable effects. The relative small cost of providing the option would make it more acceptable to stakeholders and feasible to implement. Although the panel decided the desirable and undesirable consequences were closely balanced, the following statement was provided:

 

Recommendation: For patients with recent (0-3 months) grades I to II NAD, we suggest manipulation or mobilization based on patient preference. (Weak recommendation, low-quality evidence)

 

Table 6 Multimodal Care vs Education

 

Table 7 Exercise vs No Treatment

 

Table 8 Yoga vs Education

 

Exercise

 

Key Question 2: Should integrated neuromuscular inhibition technique be used for recent-onset (0-3 months) grades I to II NAD?

 

Summary of Evidence. Nagrale et al.62 reported non� clinically significant differences for neck pain and disability outcomes at 4 weeks. This study suggested that a soft tissue therapy intervention to the upper trapezius, combining ischemic compression, strain-counterstrain, and muscle energy technique, provides similar clinical benefit compared with muscle energy technique alone. Participants were required to have neck pain of less than 3 months� duration.

 

The panel determined moderate certainty in the evidence, with small desirable and undesirable effects and no serious adverse events. Low costs are required for the intervention and no specific equipment is needed, with the exception of training to provide the technique. Because the intervention is widely practiced and taught, it is acceptable and feasible to implement. However, its effects on health equities cannot be determined. Overall, the panel decided the balance between the desirable and undesirable consequences was uncertain, and more evidence is needed before a recommendation can be made.

 

Multimodal Care

 

Key Question 3: Should multimodal care vs intramuscular ketorolac be used for recent (0-3 months) grades I to III NAD?

 

Summary of Evidence. McReynolds et al. 63 presented short-term outcomes of pain intensity and concluded that sessions of multimodal care (manipulation, soft tissue techniques) provided equivalent outcomes to an intramuscular injection of ketorolac. However, the follow-up time of 1 hour is generally atypical and the dosing was determined to be incomplete for multimodal care as reported. Furthermore, the study was limited to an emergency setting only.

 

The panel determined low certainty in the clinical evidence, with small desirable and undesirable effects. There is relatively low risk for multimodal care, considering the reported outcomes were equal. From a clinician standpoint, resources required are small assuming no additional staff are needed. However, one practitioner gave most multimodal therapies. Expenses may vary depending on the definition of multimodal care. This option should not create health inequities, except for those who cannot access clinicians or choose to pay out of pocket, and would be feasible to implement. Professional associ- ations would generally support the option, yet extended multimodal therapies can incur additional costs, which can be unfavorable to both payors and patients. Overall, the balance between the desirable and undesirable conse- quences is uncertain and more research is needed in this area before any recommendation can be made.

 

Table 9 Exercises vs Home Range or Motion or Stretching Exercises

 

Table 10 Multimodal Care vs Self-Management

 

Exercise

 

Key Question 4: Should multimodal care vs home exercises vs medication be used for recent-onset (0-3 months) grades I to II NAD?

 

Summary of Evidence. One RCT by Bronfort et al.22 evaluated the efficacy of multimodal care over 12 weeks compared with a 12-week home exercise and advice program or medication on neck pain (11-box NRS) and disability (NDI) in 181 adult patients with acute and subacute neck pain (2-12 weeks� duration and a score of ?3 on a 10-point scale). Multimodal care by a chiropractor (mean of 15.3 visits, range 2-23) included manipulation and mobilization, soft tissue massage, assisted stretching, hot and cold packs, and advice to stay active or modify activity as needed. Daily home exercise was to be done up to 6 to 8 times per day (individualized program including self- mobilization exercise of the neck and shoulder joints) with advice by a physical therapist (two 1-hour sessions, 1-2 weeks apart on posture and activity of daily living). Medication prescribed by a physician included nonsteroidal anti-inflammatory drugs (NSAIDs), acetaminophen, opioid analgesic, or muscle relaxants (dosage was not reported). The results displayed in Table 4 indicated that multimodal care and home exercises and advice were as effective as medication in reducing pain and disability at short term (26 weeks). However, medication was associated with a higher risk for adverse events (mostly gastrointestinal symptoms and drowsiness in 60% of participants) than home exercises. The choice of medications was based on the participant�s history and response to treatment. Clinicians and patients should be aware that current evidence is insufficient to determine the effectiveness of long-term opioid therapy for improving chronic pain and function. Importantly, evidence supports a dose-dependent risk for serious harms, including increased risk for overdose, dependence, and myocardial infarction.64

 

Recommendation: For patients with recent (0-3 months) neck pain grades I to II, we suggest either range-of-motion home exercises, medication, or multimodal manual therapy for reduction in pain and disability. (Weak recommendation, moderate- quality evidence)

 

Remark: Home exercises included education self-care advice, exercises, and instruction on activities of daily living. Medication included NSAIDs, acetaminophen, muscle relaxant, or a combination of these. Multimodal manual therapy included manipulation and mobilization with limited light soft tissue massage, assisted stretching, hot and cold packs, and advice to stay active or modify activity as needed.

 

Key Question 5: Should supervised graded strengthening exercises vs advice be used for recent-onset (0-3 months) grade III NAD?

 

Summary of Evidence. One RCT by Kuijper et al.65 evaluated the effectiveness of supervised strengthening exercises compared with advice to stay active for recent-onset grade III neck pain. This RCT reported that strengthening exercises (n = 70) were more effective than advice to stay active (n = 66).65 Trial participants were followed at 3 weeks, 6 weeks, and 6 months. Based on panel consensus, outcomes determined to be important in the assessment of effectiveness in this RCT included neck and arm pain (VAS) and disability (NDI). These outcomes were both statistically and clinically significant (Table 5).

 

In this RCT, the strengthening exercise program was delivered by physiotherapists 2 times per week for 6 weeks.65 It included supervised graded strengthening exercises for the shoulder and daily home exercises to strengthen the superficial and deep neck muscles (mobility, stability, and muscle strengthening). Participants in the comparison group were advised to continue daily activities. Both groups were allowed to use painkillers. See Key Question 6 for a recommendation on cervical collar.

 

Recommendation: For patients with recent (0-3 months) grade III neck and arm pain, we suggest supervised graded strengthening exercises* rather than advice alone.� (Weak recommendation, moderate-quality evidence)

 

Remark: *Supervised graded strengthening exercises con- sisted of strengthening and stability exercises twice a week for 6 weeks with daily home exercises (which included mobility, stability, and muscle strengthening). �Advice alone consisted of maintaining activity of daily living without specific treatment.

 

Table 11 Manipulation vs No Manipulation

 

Table 12 Massage vs No Treatment

 

Table 13 Multimodal Care vs Continued Practitioner Care

 

Table 14 Group Exercise vs Education or Advice

 

Table 15 General Exercise and Advice vs Advice Alone

 

Passive Physical Modalities

 

Key Question 6: Should cervical collar vs graded strengthening exercise program be used for recent-onset (0-3 months) grade III NAD?

 

Summary of Evidence. One RCT by Kuijper et al.65 randomly assigned 205 patients with recent-onset neck�cervical radiculopathy (NAD grade III) to 1 of 3 groups 1 : Rest and semi-hard cervical collar for 3 weeks, then weaned off during weeks 3-6 2 ; physiotherapy (mobilizing and stabilizing the cervical spine, standardized graded neck strengthening exercises twice per week for 6 weeks, and education to do daily home exercises); or3 a control group (wait and see with advice to continue daily activities). All patients received written and oral reassurance about the usually benign course of the symptoms and were allowed painkillers.

 

Wearing a semi-hard cervical collar or receiving standardized graded strengthening exercise program and home exercises for 6 weeks provided similar improvements in arm pain (VAS), neck pain (VAS), or disability (NDI) compared with a wait-and-see policy at 6 weeks. There were no between-group differences at 6 months.

 

Because of uncertainty about potential for iatrogenic disability associated with the prolonged use of cervical collar,27,42 one recommendation made in the current guideline favoring strengthening exercise programs over advice, and the lack of consensus among the guideline panel, the GDG decided not to make a recommendation against the use of cervical collar (first vote on the proposed recommendation with direct results from the study [11% agree, 11% neutral, 78% disagree, 1 abstained]). A second vote favored also removing the remark from the recommendation (27% agree, 9% neutral, 64% disagree, 1 did not vote). Choice should be based on patient�s preference and management changed if recovery is slow.66

 

Key Question 7: Should low-level laser therapy be used for recent-onset (0-3 months) grade III NAD?

 

Summary of Evidence. One RCT by Konstantinovic et al.67 evaluated the effectiveness of low-level laser therapy (LLLT) delivered 5 times per week for 3 weeks compared with placebo (inactive laser treatment) for recent-onset grade III neck pain. LLLT leads to statistically but not clinically significant improvements in neck pain and disability at 3 weeks compared with placebo. Transitional worsening in pain (20%) and persistent nausea (3.33%) were observed in the LLLT group, whereas no adverse events were reported in the placebo group.

 

The panel determined the overall certainty of the evidence was moderate, with small desirable effects and minor adverse events. LLLT can be expensive. If practitioners choose not to purchase, it may negatively affect health equities. However, the option is acceptable to stakeholders and is relatively easy to implement. The panel was uncertain about the balance between desirable and undesirable consequences and voted against making a recommendation because of a lack of clear evidence (LLLT was no better than placebo but both groups demonstrated within-group change over time).

 

Work Disability Prevention Interventions

 

Key Questions 8 and 9: Should work disability prevention interventions vs fitness and strengthening exercise program be used for recent-onset nonspecific work-related upper limb disorders?�Should work disability prevention interventions be used for recent-onset work-related neck and upper limb complaints?

 

In reviewing the evidence on work disability prevention interventions,41 the GDG concluded that the balance between desirable and undesirable consequences was �closely balanced or uncertain.� As a result, the guideline panel was unable to formulate recommendations for these key questions, yet future research is very likely to either positively or negatively support the various types of work disability prevention interventions.

 

Although some benefits were reported favoring computer-prompted and instructed exercise interventions,68 the incremental self-reported improvement was insufficient to formulate a recommendation considering1 a follow-up period of 8 weeks in reviewed studies is too short to estimate long-term sustained benefits; and2 the potential costs related to programming and worker instruction may be significant.

 

Overall, it appears that adding computer-prompted exercises (with workplace breaks), or workplace breaks alone, to a program of ergonomic modification and education improves self-perceived recovery and symptomatic benefits in computer workers with neck and upper back complaints.41 However, it is unclear whether the addition of computer- prompted exercises to the various established workplace interventions alters perceived or objective health outcomes. Future research may identify added benefits in order for stakeholders to consider the extra cost as being surmountable.

 

Recommendations for Recent-Onset (0-3 Months) Grades I to III WAD

 

Multimodal Care

 

Key Question 10: Should multimodal care vs education be used for recent (0-3 months) grades I to III WAD?

 

Summary of Evidence. A 2-part RCT by Lamb et al.69 evaluated the effectiveness of oral advice compared with written material for improving pain (self-rated neck pain) and disability (NDI) in patients with recent-onset grades I to III WAD. Lamb et al.69 included a total of 3851 participants with a history of WAD grades I to III of less than 6 weeks� duration who sought treatment at an emergency department. A total of 2253 participants received active management advice in the emergency department incorporating oral advice and the Whiplash Book, which included reassurance, exercises, encouragement to return to normal activities, and advice against using a collar;�1598 participants received usual care advice, including verbal and written advice along with anti-inflammatory medication, physiotherapy, and analgesics. No between-group difference was observed in self-rated neck pain and disability at 12-month follow-up and no difference in workdays lost was observed at 4-month follow-up (Table 6).

 

Lamb et al.69 included 599 participants with WAD grades I to III that persisted for 3 weeks after attending emergency departments. Three hundred participants were treated by a physiotherapist (maximum 6 sessions over 8 weeks) including psychological strategies (goal setting or pacing, coping, reassurance, relaxation, pain and recov- ery), self-management advice (posture and positioning), exercises (shoulder complex mobilization and range of motion [ROM]; cervical and scapular stability and proprioception), and cervical and thoracic spine Maitland mobilization and manipulation; a total of 299 received single-session reinforcement advice from a physiothera- pist during their previous visit to emergency department. No difference in self-rated disability was identified at 4-month follow-up; however, greater reductions in workdays lost after 8-month follow-up were determined with self-management advice over single-session rein- forcement. Similar findings were found in an earlier study.70

 

Recommendation: For adult patients with recent (0-3 months) WAD grades I to III, we suggest multimodal care over education alone. (Weak recommendation, moderate-quality evidence)

 

Remark: Multimodal care may consist of manual therapy (joint mobilization, other soft tissue techniques), education, and exercises.

 

Structured Education

 

Key Question 11: Should structured patient education vs education reinforcement be used for recent-onset (0-3 months) WAD?

 

Summary of Evidence. Lamb et al.69 reported outcomes at 4 months for self-rated disability, identifying no clinically significant differences between groups. The study sug- gested that oral advice and an educational pamphlet provide similar benefits.

 

The panel determined moderate quality in the clinical evidence, yet uncertain desirable effects with small, minor, and transient adverse events. Relatively few resources would be required for the intervention, and wide dissemination of educational materials through electronic tools can help reduce inequities. The option is acceptable to stakeholders and feasible to implement. Overall, the desirable consequences probably outweigh the undesirable consequences. The panel determined this topic and its evidence has substantial overlap with Key Question 10. Therefore, one recommendation was made, addressing both topics.

 

Recommendations for Persistent (N3 Months) Grades I to III NAD

 

Exercise

 

Key Question 12: Should supervised exercise (ie, qigong exercise) vs no treatment (wait listing) be used for persistent (N3 months) grades I to II NAD?

 

Summary of Evidence. Two RCTs (Table 7) evaluated the effectiveness of supervised qigong compared with super- vised exercise therapy and no treatment on neck pain (101-point VAS), disability (NDI), and Neck Pain and Disability Scale in a total of 240 patients with chronic neck pain (N6 months). 71,72 Rendant et al. 72 reported that, in adults with chronic neck pain, supervised qigong is more effective than no treatment and as effective as exercise therapy in reducing neck pain and disability at 3 and 6 months. Conclusions regarding the effectiveness of these 2 interventions compared with no treatment in patients aged older than 55 years cannot be drawn from the included studies.

 

In their study of these interventions for neck pain in elderly patients, von Trott et al.71 observed a reduction in pain and disability in both intervention groups at 3 and 6 months (although not statistically significant). The quality of the evidence was downgraded to low based on the SIGN criteria (concealment method not reported). In the von Trott et al. study, the interventions consisted of two 45-minute sessions per week for 3 months (a total of 24 sessions),71 whereas in the Rendant et al. study, interventions consisted of 12 treatments in the first 3 months and 6 treatments in the following 3 months (total of 18 sessions).72 Exercise therapy in both studies included repeated active cervical rotations and strengthening and flexibility exercises in the form of Dantian qigong71 or Neiyanggong qigong.72 Similar minor transient side effects were reported in both the intervention and comparison groups.

 

Recommendation: For adult patients with persistent (N6 months) neck pain grades I to II, we suggest supervised group exercises* to reduce neck pain and disability. (Weak recommendation, moderate-quality evidence)

 

Remark: Patients received 18 to 24 group sessions during a period of 4 to 6 months. Patients considered had a rating of 40/100 on a pain scale (VAS). The intervention group reached suggested MCID level of 10% difference for pain and functional outcomes. *Exercises included qigong or ROM, flexibility, and strengthening exercises. No evidence of significant effect in the elderly population.

 

Key Question 13: Should supervised yoga vs education be used for persistent (N3 months) grades I to II NAD?

 

Summary of Evidence. Yoga is an ancient Indian practice involving postural exercises, breathing control, and med-
itation. 20 One RCT by Michalsen et al. 73 evaluated the effectiveness of Iyengar yoga compared with a self-care/exercise program on neck pain (VAS) and disability (NDI) in 76 patients with chronic neck pain (pain for at least 3 months and a score of more than 40 mm on a 100-mm VAS). Yoga consisted of a weekly 90-minute session for 9 weeks of a wide range of postures aimed to enhance flexibility, alignment, stability, and mobility. The self-care/ exercise group had to practice for 10 to 15 minutes at least 3 times a week a series of 12 exercises focusing on muscle stretching and strengthening and joint mobility. The results indicated that yoga is more effective for reducing neck pain and disability at short term (4 and 10 weeks) than self-care/ exercise (Table 8). No serious adverse events were reported in either group. In this study, the quality of evidence was downgraded to low because blinding was �poorly ad- dressed.�45

 

One RCT by Jeitler et al.74 evaluated the effectiveness of Jyoti meditation compared with exercise on neck pain (VAS). The results showed that Jyoti meditation (sitting motionless, repeating a mantra, and visual concentration while keeping the eyes closed) is more effective than exercise (established and previously used self-care manual for specific exercise and education for chronic neck pain).74 Because Jyoti meditation only includes 1 of the 3 components of yoga (ie, meditation), Jeitler et al.74 was not considered in developing the following recommendation.

 

Recommendation: For patients with persistent (N3 months) grades I to II neck pain and disability, we suggest supervised yoga over education and home exercises for short- term improvement in neck pain and disability. (Weak recommendation, low-quality evidence)

 

Remark: Baseline intensity of pain was more than 40/100 and duration was at least 3 months. Yoga was specific to the Iyengar type, with a maximum of 9 sessions over 9 weeks.

 

Key Question 14: Should supervised strengthening exercises vs home ROM or stretching exercises be used for persistent (N3 months) grades I to II NAD?

 

Summary of Evidence. Three RCTs evaluated the effectiveness of supervised strengthening exercises compared with home exercises for grades I to II neck pain and disability.38 Two RCTs (Hakkinen et al.75 and Salo et al.76) reported no significant between group differences at 1 year for primary or secondary outcomes. One RCT (N = 170) reported that supervised strengthening exercises were more effective than home ROM exercises.77 Two smaller RCTs (N = 107) found that both treatments are equally effective.75,76 All 3 trials had a follow-up of 1 year. Based on our panel�s consensus, outcomes determined to be important in the assessment of effectiveness for these RCTs included pain (NRS) and disability (NDI).

 

In the RCT by Evans et al.77 the strengthening exercise program (delivered by exercise therapists) was determined to be more effective than home exercises. The program�included 20 supervised sessions over a period of 12 weeks and consisted of neck and upper body dynamic resistance strengthening program with and without spinal manipula- tive therapy.77 Conversely, the home exercises included an individualized program of neck and shoulder self- mobilization with initial advice regarding posture and daily activities (Table 9). In the 2 RCTs demonstrating equivalence, the strengthening program included 10 supervised sessions over 6 weeks of isometric exercises for the neck flexors and extensors, dynamic shoulder and upper extremity exercises, abdominal and back exercises, and squats.43,44

 

A fourth RCT by Maiers et al.78 assessed the effectiveness of supervised rehabilitative exercises in combination with and compared with home exercises alone for persistent neck pain in individuals aged 65 years or older. All participants in the study received 12 weeks of care. One group received 20 supervised 1-hour exercise sessions in addition to home exercises. Home exercises consisted of four 45- to 60-minute sessions to improve flexibility, balance, and coordination and enhance trunk strength and endurance. Participants also received instruc- tions on pain management, practical demonstrations of body mechanics (lifting, pushing, pulling, and rising from a lying position), and massaging to stay active. Results favored supervised rehabilitative exercises combined with home exercises over home exercise for pain (NRS) and disability (NDI) at 12 weeks. However, between-group differences did not reach statistical significance.

 

Recommendation: For patients with persistent (N3 months) grades I to II neck pain, we suggest supervised strengthening exercises or home exercises. (Weak recommendation, low-quality evidence)

 

Remark: For reduction in pain, supervised strength- ening exercises, provided along with ROM exercises and advice, were evaluated at 12 weeks within 20 sessions. Home exercises include stretching or self-mobilization.

 

Key Question 15: Should strengthening exercises vs general strengthening exercises be used for persistent (N3 months) grades I to II NAD?

 

Summary of Evidence. Griffiths et al.79 presented non� clinically significant outcomes for neck pain and disability among patients with persistent neck pain and concluded there is no added benefit of incorporating specific isometric exercise to a general exercise program. Dosages were up to 4 sessions per 6-week period, with advice for 5 to 10 times at home. The general exercise program consisted of postural exercise, active ROM, 5 to 10 times daily with reinforcement.

 

The panel determined there is low certainty in the clinical evidence and uncertainty in the desirable effects of the intervention. Isometric exercises have little anticipated adverse effects, require minimal resources, and are generally acceptable to stakeholders and feasible to�implement. Yet uncertainty remains regarding their effects on health equity and the overall balance between desirable and undesirable consequences. More research is needed in this area before a recommendation can be made.

 

Key Question 16: Should combined supervised strengthening, ROM, and flexibility exercises vs no treatment (wait listing) be used for persistent (N3 months) grades I to II NAD?

 

Summary of Evidence. von Trott et al. 71 and Rendant et al. 72 presented significant outcomes for reduction in neck pain and disability that favor combined strengthening, ROM, and flexibility exercises. Both studies address different popula- tions and lead to similar outcomes (von Trott et al.71 addressed elderly populations).

 

The panel determined there was moderate certainty in the clinical evidence, with large desirable and small undesirable anticipated effects. Yet there may be differences in adverse events for strengthening vs ROM and flexibility exercises, along with the chal- lenges of such adverse events being self-reported. For example, strengthening exercises likely coincide with short-term pain after the intervention. Further, signifi- cant space may be required for exercises, which may incur large costs that need to be considered up front. As a result, there is uncertainty about the feasibility to implement and whether this could widely affect health inequalities. However, the option would be acceptable to stakeholders. Overall, the desirable consequences would probably outweigh the undesirable consequences. The panel determined this topic and its evidence has substantial overlap with Key Question 12 (qigong was considered exercise). Therefore, 1 recommendation was made, addressing both topics.

 

Manual Therapy

 

Key Question 17: Should multimodal care vs self-management be used for persistent (N3 months) grades I-II NAD?

 

Summary of Evidence. One RCT by Gustavsson et al.80 evaluated the effectiveness of self-management of persis- tent musculoskeletal tension type neck pain for grades I to II neck pain. They compared treatment effects of a multicom- ponent pain and stress self-management group intervention (n = 77) to individually administered multimodal physical therapy (n = 79). Measures of pain (NRS) and disability (NDI) were collected at baseline and at 10 and 20 weeks. Both groups had within-group differences for decreased pain intensity and disability. At the 20-week follow-up after an average of 7 sessions, based on the measures used, the multicomponent pain and stress self-management group intervention had a greater treatment effect on coping with pain and patients� self-reported pain control and disability than the multimodal care group. The initial treatment effects were largely maintained over a 2-year follow-up period (Table 10).81

 

Recommendation: For patients with persistent (N3 months) neck pain and associated disorders grades I to II, we suggest multimodal care* or stress self-management� based on patient preference, prior response to care, and resources available. (Weak recommendation, low-quality evidence)

 

Remark: *Individualized multimodal care may include manual therapy (manipulation, mobilization, massage, trac- tion), acupuncture, heat, transcutaneous electrical nerve stimulation, exercise, and/or ultrasound. �Stress self-manage- ment may include relaxation, balance and body awareness exercises, pain and stress self-management lectures, and discussion. The multimodal care group received an average of 7 (range 4-8) sessions, compared with 11 (range 1-52) sessions for the stress self-management group over 20 weeks.

 

Education

 

Key Question 18: Should structured patient education vs massage therapy be used for persistent (N3 months) NAD?

 

Summary of Evidence. Sherman et al.82 reported non� clinically significant outcomes at 4 weeks for disability. This study suggests a mailed self-care book and a course in massage therapy provide similar clinical benefits for
patients with persistent neck pain.

 

The panel determined the overall certainty of the evidence was low, with relatively large anticipated effects and no serious adverse events noted from intervention (some headaches possibly). There is uncertainty in the costs required, including necessary staff, equipment, and mate- rials. Yet this option is feasible to implement in most settings and has strong implications for reducing health inequities. As a preventive strategy, the intervention is acceptable to stakeholders, including the chiropractic practitioners, patients, and policymakers. The panel was uncertain about the balance between the desirable and undesirable consequences. Additional high-quality studies are needed in this area before any recommendation can be made.

 

Manual Therapy

 

Key Question 19: Should manipulation be used for persistent grades I to II NAD?

 

Summary of Evidence. Evans et al.77 compared spinal manipulation in addition to 20 weeks of supervised exercise therapy (20 sessions) to supervised exercise therapy alone in adults with persistent grades I to II neck pain, whereas Maiers et al.78 compared spinal manipulation in addition to home exercises (20 sessions maximum) to home exercise alone in seniors with persistent grades I to II neck pain. Pain and disability outcomes at 12 and 52 weeks did not reach statistical significance in between-group differences, except for pain level at 12 weeks in the Maiers study.78 A third RCT by Lin et al.83 allocated 63 persistent neck pain patients (NAD I-II) to the experimental group (n = 33) treated with�cervical spine manipulation and traditional Chinese massage (TCM) compared with TCM alone (n = 30) over 3 weeks. Results favored cervical manipulation with TCM over TCM alone for pain (NPS) and disability (Northwick Park Neck Disability Questionnaire) at 3 months (Table 11).

 

The panel concluded low certainty in the evidence, with small desirable and undesirable effects of the intervention. Few resources are required for the intervention, and it is probably acceptable to stakeholders and feasible to implement. Although the panel decided the desirable and undesirable consequences were closely balanced, the following statement was provided.

 

Recommendation: For patients with persistent grades I to II NAD, we suggest manipulation in conjunction with soft tissue therapy. (Weak recommendation, low-quality evidence)

 

Remark: Evaluated after eight 20-minute sessions (over a 3-week period). Does not include manipulation as a standalone treatment.

 

Manual Therapy

 

Key Question 20: Should massage vs no treatment (wait listing) be used for persistent (N3 months) grades I to II NAD?

 

Summary of Evidence. Sherman et al.82 and Lauche et al.84 reported non�clinically significant differences in outcomes for disability at 4 and 12 weeks, respectively. Sherman et al.82 suggested Swedish and/or clinical massage with verbal self- care advice provides similar clinical benefit to a self-care book for disability outcomes. Lauche et al.84 suggested cupping massage and progressive muscle relaxation lead to similar changes in disability. Sherman et al.85 reported outcomes for neck pain and disability at 4 weeks and suggested that higher doses of massage provide superior clinical benefit (Table 12).

 

The panel determined low certainty in the evidence, with small desirable and undesirable effects. Additional costs may be needed to get clinical benefit. Sherman et al.85 suggested a minimum of 14 hours of staff time needed. Because of the costs associated with high-dose massage, it may not be entirely acceptable to patients or payors. However, this option is feasible and relatively easy to implement in educated and affluent populations similar to subjects primarily studied.85 Overall, the panel decided the desired consequences probably outweigh the undesirable consequences and suggest offering this option.

 

Recommendation: For patients with persistent (N3 months) grades I to II NAD, we suggest high-dose massage over no treatment (wait listing) based on patient preferences and resources available. (Weak recommendation, low-quality evidence)

 

Remark: Interventions were given 3 times for 60 minutes a week for 4 weeks. Lower dosages and duration did not have therapeutic benefit, and we cannot suggest offering as an option.

 

Passive Physical Modalities

 

Key Question 21: Should LLLT be used for persistent (N3 months) grades I to II NAD?

 

Summary of Evidence. After full-text screening and review, no studies addressing between-group differences among outcomes of pain or disability were included to inform this key question. The lack of evidence and uncertainty in the overall balance between desirable and undesirable consequences led the panel to decide not to write a recommendation for this topic at this time. More high-quality studies are needed in this area before certainty in judgments or recommendations can be made.

 

Key Question 22: Should transcutaneous electrical nerve stimulation vs multimodal soft tissue therapy program be used for persistent (N3 months) grades I to II NAD?

 

Summary of Evidence. After full-text screening and review, no studies addressing between-group differences among outcomes of pain or disability were included to inform this key question. The lack of evidence and uncertainty in the overall balance between desirable and undesirable consequences led the panel to decide not to write a recommendation for this topic at this time. More high quality studies are needed in this area before certainty in judgments or recommendations can be made.

 

Key Question 23: Should cervical traction be used for grade III NAD (variable duration)?

 

Summary of Evidence. After full-text screening and review, no studies addressing between-group differences among outcomes of pain or disability were included to inform this key question. The lack of evidence and uncertainty in the overall balance between desirable and undesirable consequences led the panel to decide not to write a recommendation for this topic at this time. More high-quality studies are needed in this area before certainty in judgments or recommendations can be made.

 

Multimodal Care

 

Key Question 24: Should multimodal care vs continued practitioner care be used for persistent grades I to III NAD?

 

Summary of Evidence. One RCT by Walker et al.86 evaluated the effectiveness of multimodal care for neck pain with or without unilateral upper extremity symptoms (grades I-III). They compared treatment effects of combined multimodal care and home exercises (n = 47) to multimodal minimal intervention (n = 47). Both intervention groups received on average of 2 sessions per week for 3 weeks. No interventions were rendered after 6 weeks. Baseline self- reported questionnaires included neck and arm pain (VAS) and disability (NDI). All measures were repeated at 3, 6, and 52 weeks. Patients in the multimodal care and home exercise group had significantly greater reduction in short-term neck pain and in short-term and long-term disability compared with the multimodal minimal interven- tion group (Table 13). A secondary analysis of the Walker et al. study87 determined that patients receiving both�cervical thrust and nonthrust manipulations did no better than the group receiving cervical nonthrust manipulations only. This underpowered secondary analysis prohibits any definitive statement regarding the presence or absence of a treatment advantage of one approach over the other. The reduction in pain reported by Walker�s multimodal care and exercise group compared favorably to the change scores reported by other studies, including Hoving et al.88,89

 

In an RCT, Monticone et al.90 evaluated the effective- ness of multimodal care for persistent neck pain. They compared treatment effect of multimodal care alone (n = 40) to multimodal care in conjunction with cognitive behavioral treatment (n = 40). Both groups had a reduction in pain (NRS) and disability (NPDS), but there were no clinically significant differences between the groups at 52 weeks. The addition of a cognitive behavioral treatment did not provide greater outcomes than multimodal care alone.

 

Recommendation: For patients presenting with persistent neck pain grades I to III, we suggest clinicians offer multimodal care* and/ or practitioner advice based on patient preference. (Weak recommendation, low-quality evidence)

 

Remark: *Multimodal care and exercises may consist of thrust/nonthrust joint manipulation, muscle energy, stretching, and home exercises (cervical retraction, deep neck flexor strengthening, cervical rotation ROM). �Multimodal minimal intervention may consist of postural advice, encouragement to maintain neck motion and daily activities, cervical rotation ROM exercise, instructions to continue prescribed medication, and therapeutic pulsed (10%) ultrasound at 0.1 W/cm2 for 10 minutes applied to the neck and cervical ROM exercises.

 

Exercise

 

Key Question 25: Should group exercises vs education or advice be used for workers with persistent neck and shoulder pain?

 

Summary of Evidence. We have combined the key questions for �Should structured patient education vs exercise programs be used for persistent neck pain and associated disorders in workers?� and �Should workplace-based exercises vs advice be used for neck pain in workers?� One large cluster RCT (n = 537) by Zebis et al.91 evaluated the effectiveness of strength training in the workplace compared with receiving advice to stay physically active on nonspecific neck and shoulder pain intensity. The findings indicated a similar reduction in neck and shoulder pain intensity at 20 weeks for the exercise program compared with advice (Table 14). The intervention consisted of 3 sessions per week, each lasting 20 minutes, for up to 20 weeks (total of 60 sessions).

 

The workplace exercise program consisted of high- intensity strength training relying on principles of progres- sive overload and involved local neck and shoulder muscles strengthening with 4 different dumbbell exercises and 1 exercise for the wrist extensor muscles. More than 15% of�workers assigned to the workplace exercise group reported minor and transient complaints. The comparison group reported no adverse events.

 

A subgroup analysis92 of the primary Zebis et al. study91 included 131 women with a baseline neck pain rating of at least 30 mm VAS from the 537 male and female participants. Results favored specific resistance training over advice to stay active for pain (VAS) at 4 weeks. This study was not included because findings were already considered in the primary study.

 

Recommendation: For workers with persistent neck and shoulder pain, we suggest mixed supervised and unsupervised high- intensity strength training or advice alone. (Weak recommendation, moderate-quality evidence)

 

Remark: For reduction in pain intensity, 3 sessions per week, each lasting 20 minutes, over a 20-week period. Exercise includes strengthening. Extra resources are likely required for complete exercise intervention implementation.

 

Structured Patient Education

 

Key Question 26: Should structured patient education vs exercise programs be used for persistent (N3 months) NAD in workers?

 

Summary of Evidence. Andersen et al.93 reported non� clinically significant outcomes at 10 weeks for neck and shoulder pain, suggesting weekly e-mailed information on general health behaviors and shoulder abduction exercise programs provide similar clinical benefit. Yet implementa- tion of high-intensity strength training exercises in industrial workplaces (implementation of exercise into day-to-day life and to increase active leisure time) is generally supported.94,95 In another RCT, pain reduction was significantly greater than in the group receiving advice alone. 91 Findings from Zebis et al. 91 are also included in the exercise intervention section of this guideline.

 

The panel determined moderate certainty in the clinical evidence, with small desirable and undesirable effects of the intervention. The resources required are relatively small, assuming the practitioner presents the education to the patient. Health inequities would be positively affected, and the intervention would be acceptable to stakeholders and feasible to implement. The panel decided not to repeat these findings in the current section. The panel felt that the benefits of increasing the frequency and intensity of exercise regimes was not restricted to those working in an industrial environment or to any specific population subgroup with the exception of older adults.

 

Work Disability Prevention Interventions

 

Key Questions 27-29: Should work-based hardening vs clinic-based hardening be used for persistent (N3 months) work-related rotator cuff tendinitis? Should work disability prevention interventions be used for persistent neck and shoulder pain?�Should work disability prevention interventions be used for persistent (N3 months) upper extremity symptoms?

 

Table 16 Treatment Interventions Not to be Offered for NAD

 

Summary of Evidence. In reviewing the evidence on work disability prevention interventions,41 the GDG concluded that the balance between desirable and undesirable consequences was �closely balanced or uncertain� for Key Questions 27-29. As a result, the guideline panel was unable to formulate recommendations for these key questions, yet future research is very likely to either positively or negatively support the various types of work disability prevention interventions.

 

Recommendations for Persistent (N3 Months) Grades I to III WAD Exercise

 

Key Question 30: Should supervised general exercise and advice vs advice alone be used for persistent (N3 months) grades I to II WAD?

 

Summary of Evidence. In an RCT, Stewart et al. (2007)96 evaluated the effectiveness of 3 advice sessions alone compared with 3 advice sessions combined with 12 exercise sessions over 6 weeks on neck pain (NRS) and disability�(NDI) among 134 patients with persistent grades I to II WAD. The results, presented in Table 15, indicated that supervised exercises with advice are as effective as advice alone at long term (12 months). Advice included standardized education, reassurance, and encouragement to resume light activity and consisted of 1 consultation and 2 follow-up phone contacts. However, the quality of the evidence was downgraded to low based on SIGN criteria (randomization and outcome measurement were �poorly addressed�) and the low number of participants and events.45

 

A pragmatic trial assigned 172 patients with persistent WAD grades I to II to receive a comprehensive 12-week exercise program (20 sessions including manual therapy technique the first week [no manipulation] and cognitive behavioral therapy delivered by physiotherapists) or advice (1 session and telephone support).97 The comprehensive exercise program was not more effective than advice alone for pain reduction or disability, although findings favored a comprehensive physiotherapy exercise program over advice.

 

The panel determined low certainty in the evidence, with small desirable and undesirable effects and no serious adverse events (5 patients who received the comprehensive exercise program and 4 who received advice had minor transient adverse events). Overall, the panel decided the balance between the desirable and undesirable conse- quences such as costs was uncertain, and more evidence is needed before a recommendation can be made.

 

In a 20-week cluster RCT, Gram et al. (2014)98 randomly assigned 351 office workers to 2 training groups receiving the same total amount of planned exercises 3 times per week, with 1 group supervised throughout the intervention period and the other receiving minimal supervision only initially, and a reference group (without exercise). Although results indicated that supervised training at the workplace reduced neck pain, results were not clinically significant and both training groups improved independently of the extent of supervision. The panel decided not to consider this study in formulating a recommendation because exercise was not directly com- pared with advice and an important loss to follow-up occurred across groups. Although supervised exercise appears to be beneficial, costs can be high. This could possibly be mitigated, however, by offering group treat- ment, which may increase compliance and accountability with a supervised group.

 

Recommendation: For patients with persistent (N3 months) grades I to II WAD, we suggest supervised exercises with advice or advice alone based on patient preference and resources available. (Weak recommendation, low-quality evidence)

 

Remark: Extra resources may be required for supervised exercises.

 

Multimodal Care

 

Key Question 31: Should multimodal care vs self- management program be used for persistent (N3 months) grade II WAD?

 

Summary of Evidence. Jull et al.99 reported no clinically or statistically significant outcomes for pain and disability at 10 weeks. They suggested that multimodal care (exercises, mobilization, education, and ergonomic advice) provided similar outcomes to a self-management program based on an educational booklet (mechanism of whiplash, reassur- ance of recovery, stay active, ergonomic advice, exercise). Care did not include high-velocity manipulation. Although this study is specific to physiotherapists, it is well within the scope of chiropractors (manual therapists).

 

One other RCT by Jull et al.100 evaluated the effectiveness of multidisciplinary individualized treat- ments for patients with acute whiplash (b4 weeks postinjury). Patients randomly assigned to pragmatic intervention (n = 49) could receive medication including opioid analgesia, multimodal physiotherapy, and psy- chology for post-traumatic stress over 10 weeks. No significant differences in frequency of recovery (NDI ? 8%) between pragmatic and usual care groups was found at 6 or 12 months. There was no improvement in current nonrecovery rates at 6 months (63.6%, pragmatic care; 48.8%, usual care), indicating no advantage of the early multiprofessional intervention.

 

The panel determined low certainty in the clinical evidence, with small desirable and undesirable effects reported. Yet there were relatively small costs and resources required to implement the intervention. Electronic dissem- ination of the educational component of multimodal care may reduce health inequities. The option may be acceptable to clinicians (assuming collaborative care approaches), policymakers, and patients and is likely feasible to implement in usual care settings. Overall, the balance between the desirable and undesirable consequences is uncertain, and no recommendation is given at this time. Further studies need to be conducted in this area and should involve multimodal care including high-velocity proce- dures or manipulation.

 

Education

 

Key Question 32: Should structured patient education vs advice be used for persistent (N3 months) WAD?

 

Summary of Evidence. Stewart et al. (2007)96 reported non�clinically significant between differences for pain and disability outcomes at 6 weeks. This study suggested that adding a physiotherapy-based graded exercise program to a structured advice intervention provided similar clinical benefit as structured education alone.

 

The panel determined low certainty of the evidence, with low desirable and undesirable anticipated effects. The main complaints were muscle pain, knee pain, and spinal pain with mild headaches.96 The small resources required for the intervention may reduce health inequities, and the option is acceptable to stakeholders and feasible to implement in most settings.

 

The panel determined that this key question had substantial overlap with Key Question 5 and decided to make 1 recommendation addressing both topics.

 

Discussion

 

This evidence-based guideline establishes the best practice for the management of NAD and WAD resulting from or aggravated by a motor vehicle collision and updates 2 previous guidelines on similar topics.24,25 This guideline covers recent-onset (0-3 months) and persistent (N3 months) NADs and WADs grades I to III. It does not cover the management of musculoskeletal thoracic spine or chest wall pain.

 

The primary outcomes reported in the selected studies were neck pain intensity and disability. Although all recommendations included in this guideline are based on low risk of bias RCTs, the overall quality of evidence is generally low considering other factors considered by GRADE such as imprecision, and thus the strength of recommendations is weak at this time. Weak recommen- dations mean that clinicians need to devote more time to the process of shared decision making and ensure that the informed choice reflects patient values and preferences.56 Interventions not described in this guideline cannot be recommended for the management of patients with NAD or WAD because of a lack of evidence about their effective- ness and safety (Table 16).

 

A recent systematic review and meta-analysis by Wiangkham (2015)101 on the effectiveness of conservative management for acute WAD grade II included 15 RCTs, all assessed as high risk of bias (n = 1676 participants), across 9 countries. Authors concluded that conservative interven- tions (noninvasive treatment), including active mobilization exercises, manual techniques, physical agents, multimodal therapy, behavioral approaches, and education, are gener- ally effective for recent-onset WAD grade II to reduce pain in the medium and long term and to improve cervical ROM in the short term compared with standard or control intervention.101 Although findings from the Wiangkham review are generally in line with those from the systematic reviews we included in this guideline,24,25 the pooling of high risk of bias and of clinically heterogeneous trials seriously challenges the validity of this more recent review.

 

Similarities and Differences With Recommendations by the OPTIMa Collaboration

 

First, the recommendations for the management of minor injuries of the neck were recently released by the Ministry�of Finance of Ontario in collaboration with the OPTIMa Collaboration 20 and published as a separate guideline. 27 They considered the risks of bias of included RCTs using the SIGN criteria45 and the guideline recommendations developed using the modified OHTAC framework,28 based on 3 decision determinants1: overall clinical benefit (evidence of effectiveness and safety) 2 ; value for money (evidence of cost-effectiveness where available); and3 consistency with expected societal and ethical values. In the current guideline, we used the GRADE approach, which, in addition to considering risk of bias of included RCTs, takes into account 4 other factors (imprecision, inconsistency, indirectness, publication bias) to rate the confidence in effect estimates (quality of evidence) for each outcome.102 As a result of imprecision of estimates in several RCTs, the overall quality of admissible studies was deemed low. GRADE considers similar decision determi- nants as the modified OHTAC to develop recommendations when subsequently making an overall rating of confidence in effect estimates across all outcomes based on those outcomes considered critical to a particular recommenda- tion.56 Accordingly, the guideline panel was asked to consider this low quality of evidence when judging the �desirable� consequences. When the benefits of important outcomes slightly outweighed undesirable effects of the intervention, a weak recommendation was made (ie, suggestions for care). This is likely to involve ensuring patients understand the implications of the choices they are making, possibly using a formal decision aid.56 However, if the judgment was �closely balanced or uncertain,� no recommendation could be made.

 

Second, OPTIMa 20 recommended that interventions should only be provided in accordance with published evidence for effectiveness, including parameters of dosage, duration, and frequency, and within the most appropriate phase. The emphasis during the early phase (0-3 months) should be on education, advice, reassurance, activity, and encouragement. Health care professionals should be encouraged to consider watchful waiting and clinical monitoring as evidence-based therapeutic options during the acute phase. For injured persons requiring therapy, time-limited and evidence-based interventions should be implemented on a shared decision-making basis, an approach that equally applies to patients in the persistent phase (4-6 months). Despite using slightly different methods to derive recommendations, the 2 processes generally led to similar guidance.

 

Third, OPTIMa20 reported that the following interven- tions are not recommended for recent-onset NAD: struc- tured patient education alone (either verbal or written); strain-counterstrain or relaxation massage; cervical collar; electroacupuncture (electrical stimulation of acupuncture points with acupuncture needles or electrotherapy applied to the skin), a topic not covered in our guideline; electric muscle stimulation; heat (clinic based). Similarly for�persistent NAD, programs solely of clinic-based supervised high-dose strengthening exercises, strain-counterstrain or relaxation massage, relaxation therapy for pain or disability outcomes, transcutaneous electrical nerve stimulation (TENS), electric muscle stimulation, pulsed shortwave diathermy, heat (clinic based), electroacupuncture, and botulinum toxin injec- tions are not recommended. In contrast, based on the RCT by Zebis et al.91 the current guideline suggests offering multimodal care and/or patient education for industrial workers presenting with neck pain grades I to III. Although structured patient education used alone cannot be expected to yield large benefits for patients with neck pain, this strategy may be of benefit during the recovery of patients with persistent WAD when used as an adjunct therapy.40 For persistent neck pain (grades I-II), Gustavsson et al.80 reported that multimodal care combining manual therapy (spinal manipulation, mobilization, massage, traction) and passive modalities (heat, TENS, exercise, and/or ultrasound) reduced neck disability. It should be noted, however, that past reviews were unable to make any definitive conclusions about the effectiveness of TENS as an isolated treatment for acute pain 103 or chronic pain 104 in adults, nor about the effectiveness of heat therapy.105,106

 

A comparison of the recommendations with 2 previous chiropractic guidelines 24,25 reveals that a multimodal approach including manual therapy, advice, and exercise remains the overall recommended strategy of choice for the treatment of neck pain. However, treatment modalities included in recommended multimodal care differed accord- ing to the quality of the evidence available at the time. The 2010 guideline on the management of WAD developed treatment recommendations based on low-quality evidence from 8 available RCTs and 3 cohort studies.25 Overall, recommendations for recent and persistent WAD are similar (multimodal care, and supervised exercise and multidisciplinary care, respectively). The 2014 guideline on neck pain24 developed 11 treatment recommendations from 41 RCTs. The current guideline developed 13 recommenda- tions from 26 low risk of bias RCTs. In line with the 2014 guideline24 for recent-onset neck pain, the current recom- mendations suggest offering multimodal care including mobilization, advice, and exercises. The current guideline recommendations also suggest offering supervised graded strengthening and stability exercises. Similar to the 2014 guideline for persistent neck pain (grades I-II),24 the current recommendations suggest offering multimodal care consisting of manual therapy (spinal manipulation therapy or mobilization) and exercises. Details on specific exercise modalities are now provided, including suggestions for supervised and unsuper- vised exercises, strength training, and supervised group exercises such as workplace exercise programs and supervised yoga.

 

Adverse Events

 

This guideline did not specifically review the evidence on adverse events from treatments. However, in the review�by Wong et al.42 on manual therapy and passive modalities, 22 of the low risk of bias RCTs addressed the risk of harm from conservative care. Most adverse events were mild to moderate and transient (mostly increased stiffness and pain at the site of treatment, with a mean rate of about 30%). No serious neurovascular adverse events were reported. Another review of published RCTs and prospective cohort studies confirmed that around half of people treated with manual therapy can expect minor to moderate adverse events after treatment, but that the risk of major adverse events is small.107 The pooling of data from RCTs of manual therapy on the incidence of adverse events indicated that the relative risk of minor or moderate adverse events was similar for manual therapy and exercise treatments, and for sham/passive/control interventions.

 

A patient-centered holistic and collaborative view of the needs of the patient with pain and disability is encouraged. 108,109 Although chiropractors are not responsible for pharmacologic management, they should have sufficient knowledge about pharmacologic agents and their adverse events. One eligible RCT22 found home exercises and advice to be as effective as medication (acetaminophen, NSAIDs, muscle relaxant, and opioid analgesic) in reducing pain and disability at short term for patients with acute or subacute neck pain grades I to II. However, medication was associated with a higher risk for adverse events. Of interest, recent evidence suggests that acetaminophen is not effective for managing low back pain,110,111 and the effectiveness of long-term opioid therapy for improving chronic pain and function is uncertain.64 However, a dose-dependent risk for serious harms is associated with long-term use of opioid (increased risk for overdose, opioid abuse and dependence, fractures, myocardial infarction, and use of medications to treat sexual dysfunction).64 Risk of unintentional opioid overdose injury appears to be particularly important in the first 2 weeks after initiation of long-acting agents.112,113

 

Recommendations

 

I. Stakeholders

 

Choosing a Care Provider. A range of health care providers (chiropractors, general medical practitioners, physiothera- pists, registered massage therapists, and osteopaths) deliver care for NADs and WADs.108,114 Considering the level of skills required to deliver manual therapy, including spinal manipulative therapy and other forms of therapies (eg, prescription of specific exercise) and based on individual patient preference, cervical spine manipulation as part of multimodal care should be delivered by properly trained licensed professionals. 115

 

II. Practitioners

 

Best Practice Recommendations-Initial Assessment and Monitoring.

 

This guideline specifically addresses the treatment of NAD and WAD grades I to III. Importantly, our panel supports�the following 5 best practice recommendations on patients care outlined in the OPTIMa guideline27: Clinicians should1 rule out major structural or other pathologic conditions as the cause of neck pain�associated disorders before classifying as grade I, II, or III2; assess prognostic factors for delayed recovery3; educate and reassure patients about the benign and self-limited nature of the typical course of NAD grades I to III and the importance of maintaining�activity and movement4; refer patients with worsening symptoms and those who develop new physical or psychological symptoms for further evaluation at any time during their care; and5 reassess the patient at every visit to determine whether additional care is necessary, the condition is worsening, or the patient has recovered. Patients reporting significant recovery should be discharged. Similar recommendations were formulated by the Neck Pain Task Force116 and in prior practitioner guides on the management of WAD and NAD by chiropractors.24,25

 

Benefits of Physical Activity and Self-management. Educating patients about the benefits of being physically active and participating in their care has become the standard of care internationally. Despite the benefits of therapeutic exercise for managing chronic neck pain and the strong evidence favoring regular physical activity to reduce related comorbidities, care providers fail to routinely prescribe these to patients.117-120 When prescribed, the amount of supervision and types of exercises do not follow practice guidelines and are not linked to the degree of patient impairment.118,121 On the patient side, adherence to prescribed exercise programs is often low. 122

 

The promotion of physical activity, including exercise, is a first-line treatment considered important in the prevention and treatment of musculoskeletal pain and its related comorbidities (eg, coronary heart disease, type 2 diabetes, and depression).123-126 For a minority of patients with chronic spine pain, clinician-delivered interventions and pharmacologic treatments are appropriate; and in fewer cases, multidisciplinary pain management or surgery may be indicated. 118

 

People with musculoskeletal pain will often adopt an inactive lifestyle. Unfortunately, physical inactivity is associated with important adverse health effects, including increased risks of coronary heart disease, type 2 diabetes, and breast and colon cancers, and shorter life expectancy in general.127 The World Health Organization128 provided clear guidance on physical activity for health for children, adults, and elders. In addition, recent research suggests that WAD patients with high levels of passive coping�strategies have slower pain and disability recovery.129 Self-management support (SMS) strategies aimed at increasing physical activity and active coping strategies are key to effectively managing spinal pain and related comorbidities. 124,125,130-134 The CCGI developed a theory-based knowledge translation (KT) intervention targeting identified barriers to professional behavior change to increase the uptake of SMS strategies among Canadian chiropractors.135 Interviews of clinicians identified 9 theoretical domains as likely relevant (ie, factors perceived to influence the use of multimodal care to manage nonspecific neck pain).135 The intervention, comprising a webinar and a learning module on Brief Action Planning, is a highly structured SMS strategy that allows patient- centered goals136 and is being pilot-tested among Canadian chiropractors (ongoing pilot trial).137 Care providers are encouraged to perform periodic clinical revaluations and to monitor patient progression of self-management strategies while discouraging dependence on passive treatment.

 

Figure 6 Algorithm of Recommendations for Managing NAD

 

Figure 7 Algorithm of CCGI Recommendations for WAD

 

Figure 8 CCGI Patient Information Sheet

 

III. Research

 

Overall, the quality of the research on conservative management of NADs and WADs remains low, partly explaining that only weak recommendations could be formulated for clinical practice. Further, the reporting of RCTs remains suboptimal. 138 Past recommendations for improving the quality of the research still apply.24,25 Future research should aim to clarify the role of spinal manipulation therapy alone or as part of multimodal care for the management of recent neck pain and have adequate frequency and length of follow-up. For instance, a large number of patient visits to the emergency departments each year are for acute neck and arm pain resulting from WADs.14,139 A small RCT suggested that cervical spine manipulation is a reasonable alternative to intramuscular NSAID for immediate pain relief in these patients.63 However, the small sample size, comparison of a single session of spinal manipulation to an NSAID injection, and a 1-day follow-up was not representative of clinical practice.

 

Few recent adequately controlled high-quality research studies of chiropractic care for NADs have been published. In addition, studies included in the reviews did not estimate the maximum therapeutic benefits (ie, best dosage for treatment under evaluation). Well-designed clinical trials with sufficient numbers of participants, longer-term treatments, and follow-up periods are needed to increase the confidence in the recommendations and to advance our understanding of effective and cost-effective conservative care, and spinal manipulation, for the management of patients with NADs and WADs.

 

Dissemination and Implementation Plan. Evidence-based practice aims to improve clinical decision making and patient care.140,141 When followed, CPGs have the potential to improve health outcomes and the efficiency of the health care system.142-144 However, low adherence to CPGs has been noted across health care sectors145 and in the management of musculoskeletal conditions, including NADs and WADs.77,101,102 Such gaps contribute to wide geographic variations in the use and quality of health care services. 146

 

Efforts to bridge the �research-practice gap� have led to a growing interest in KT.145,147 Knowledge translation is defined as the exchange, synthesis, and ethically sound application of knowledge to improve health and provide more effective health services. 148 Knowledge translation aims to bridge the research-practice gap and improve patient outcomes by promoting the integration and exchange of research and evidence-based knowledge into clinical practice.

 

To prepare for guideline implementation, we considered the Guideline Implementation Planning Checklist 149 and�available strategies and supporting evidence141,150 to increase guideline uptake. Although effects of KT inter- ventions tend to be modest, they are likely important at a population health level.37

 

To raise awareness, chiropractic professional organiza- tions are encouraged to inform their members of new CCGI guidelines and tools easily accessible on our website (www. chiroguidelines.org). The guideline implementation tools framework was used to clarify the objectives of the tools; identify end users and the context and setting where tools will be used; provide instructions for use; and describe methods to develop the tools and related evidence and to evaluate the tools.151 Implementation tools designed to increase guideline uptake include practitioner and patients� handouts (Fig. 8, Appendix 7); algorithms (Figs. 6 and 7), webinars, videos, and learning modules (http://www.cmcc. ca/CE); point-of-care checklists; and health status reminders.152-154 The CCGI has established a network of opinion leaders across Canada (www.chiroguidelines.org). Based on successful efforts to implement a WAD guideline in Australia using opinion leaders among regulated physiotherapists, chiropractors, and osteopaths, 155 the CCGI is planning a series of implementation studies among Canadian chiropractors.137 We will also pilot within chiropractic practice-based research networks.156 Monitor- ing guideline use in chiropractic is challenging because the use of electronic health records to routinely collect clinical practice information is not common in Canada and those using electronic health records often collect different indicators. 157 Nonetheless, the frequency of downloads (posting of the open access guideline on the CCGI website) and number of registering participants and completion of educational online material (webinar, video, and learning module) will be monitored monthly as proxy measures of guideline uptake.

 

Guideline Update

 

The methods for updating the guideline will be as follows: 1) Monitoring changes in evidence, available interventions, importance and value of outcomes, resources available or relevance of the recommendations to clinicians (limited systematic literature searches each year for 3-5 years and survey to experts in the field annually): 2) assessing the need to update (relevance of the new evidence or other changes, type and scope of the update); and 3) communi- cating the process, resources, and timeline to the Guideline Advisory Committee of the CCGI, who will submit a recommendation to the Guideline Steering Committee to make a decision to update and schedule the process.158-163

 

Strengths and Limitations

 

Shortcomings for this guideline include the low quantity and quality of supporting evidence found during the searches. Most of the downgrading of evidence supporting the outcomes occurred because of imprecision. In addition, our updated search of the published reports included 2 databases (Medline and Cochrane Central Register of Controlled Trials) but was limited to the English published reports, which possibly excluded some relevant studies. This, however, is an unlikely source of bias.164,165 Qualitative studies that explored the lived experience of patients were not included. Thus, this review cannot comment on how patients valued and experi- enced their exposure to manual therapies or passive physical modalities. Although the composition of the guideline panel was diverse, with experienced methodologists, expert clini- cians, and stakeholder and patient representatives, only 1 member was from another health discipline (physiotherapist). The scope of this guideline focused on selected outcomes such as pain and disability, although included studies assessed several additional outcomes.

 

Conclusion

 

This CPG supersedes the original (2005) and revised (2014) neck pain guideline as well as the 2010 whiplash-associated guidelines produced by the Canadian Chiropractic Association (CCA); Canadian Federation of Chiropractic Regulatory and Educational Accrediting Boards (CFCREAB).

 

People should receive care based on evidence-based therapeutic options. Based on patient preference and resources available, a mixed multimodal approach includ- ing manual therapy and advice about self-management and exercise (supervised/unsupervised or at home) may be an effective treatment strategy for recent-onset and persistent NAD and WAD grades I to III. Progress should be regularly monitored for evidence of benefit, in particular on the basis of pain alleviation and reduction of disability.

 

Funding Sources and Conflicts of Interest

 

Funds provided by the Canadian Chiropractic Research Foundation. The views of the funding body have not influenced the content of the guideline. No conflicts of interest were reported for this study.

 

Guideline Disclaimer

 

The evidence-based practice guidelines published by the CCGI include recommendations intended to optimize patient care that are informed by a systematic review of evidence and an assessment of the benefits and harms of alternative care options.21 Guidelines are intended to inform clinical decision making, are not prescriptive in nature, and do not replace professional chiropractic care or advice, which always should be sought for any specific condition. Furthermore, guidelines may not be complete or�accurate because new studies that have been published too late in the process of guideline development or after publication are not incorporated into any particular guideline before it is disseminated. CCGI and its working group members, executive committee, and stakeholders (the �CCGI Parties�) disclaim all liability for the accuracy or completeness of a guideline, and disclaim all warranties, expressed or implied. Guideline users are urged to seek out newer information that might impact the diagnostic and/or treatment recommendations contained within a guideline. The CCGI Parties further disclaim all liability for any damages whatsoever (including, without limitation, direct, indirect, incidental, punitive, or consequential damages) arising out of the use, inability to use, or the results of use of a guideline, any references used in a guideline, or the materials, information, or procedures contained in a guideline, based on any legal theory whatsoever and whether or not there was advice of the possibility of such damages.

 

Through a comprehensive and systematic literature review, CCGI evidence-based CPGs incorporate data from the existing peer-reviewed literature. This literature meets the prespecified inclusion criteria for the clinical research question, which CCGI considers, at the time of publication, to be the best evidence available for general clinical information purposes. This evidence is of varying quality from original studies of varying methodological rigor. CCGI recommends that performance measures for quality improvement, performance-based reimbursement, and public reporting purposes should be based on rigorously developed guideline recommendations.

 

Contributorship Information

 

Ncbi.nlm.nih.gov/pubmed/27836071

 

Practical Applications

 

  • A multimodal approach including manual therapy, self-management advice, and exercise can be an effective treatment strategy for recent-onset and persistent neck pain and whiplash-associated disorders.

 

Acknowledgements

 

We thank the following people for their contributions to this paper: Dr. John Riva, DC, observer; Heather Owens, Research Coordinator, proofreading; Cameron McAlpine (Director of Communication & Marketing, Ontario Chiro- practic Association), for assistance in producing the companion document intended for patients with NAD; members of the guideline panel who served on the Delphi consensus panel, who made this project possible by generously donating their expertise and clinical judgment.

 

Appendixes and Other Information

 

Ncbi.nlm.nih.gov/pubmed/27836071

 

In conclusion, whiplash-associated disorders can cause damage to the complex structures of the cervical spine, or neck, because the sheer force of an impact can extend the soft tissues beyond their natural range of motion. Many healthcare professionals can safely and effectively treat whiplash as well as other automobile accident injuries. The results of the article above demonstrate that a multimodal approach, including manual therapy, self-management advice and exercise can be an efficient treatment strategy for both recent-onset and persistent neck pain caused by whiplash-associated disorders.�Information referenced from the National Center for Biotechnology Information (NCBI). The scope of our information is limited to chiropractic as well as to spinal injuries and conditions. To discuss the subject matter, please feel free to ask Dr. Jimenez or contact us at 915-850-0900 .

 

Curated by Dr. Alex Jimenez

 

Green-Call-Now-Button-24H-150x150-2-3.png

 

Additional Topics: Back Pain

 

According to statistics, approximately 80% of people will experience symptoms of back pain at least once throughout their lifetimes. Back pain is a common complaint which can result due to a variety of injuries and/or conditions. Often times, the natural degeneration of the spine with age can cause back pain. Herniated discs occur when the soft, gel-like center of an intervertebral disc pushes through a tear in its surrounding, outer ring of cartilage, compressing and irritating the nerve roots. Disc herniations most commonly occur along the lower back, or lumbar spine, but they may also occur along the cervical spine, or neck. The impingement of the nerves found in the low back due to injury and/or an aggravated condition can lead to symptoms of sciatica.

 

blog picture of cartoon paperboy big news

 

EXTRA IMPORTANT TOPIC:�Neck Pain Treatment El Paso, TX Chiropractor

 

 

MORE TOPICS: EXTRA EXTRA: El Paso, Tx | Athletes

 

Blank
References

1. Ferrari R, Russell A. Regional musculoskeletal conditions: neck pain. Best Pract Res Clin Rheumatol. 2003;17(1):57-70.
2. Hogg-Johnson S, van der Velde G, Carroll LJ, et al. The burden and determinants of neck pain in the general population: results of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders. Spine.
2008;33(4 Suppl):S39-S51.
3. Holm L, Carroll L, Cassidy JD, et al. The burden and
determinants of neck pain in whiplash-associated disorders after traffic collisions: results of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders. Spine. 2008;33(4 Suppl):S52-S59.
4. Co?te? P, van der Velde G, Cassidy JD, et al. The burden and determinants of neck pain in workers: results of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders. Spine. 2008;33(4 Suppl): S60-S74.
5. Vos T, Flaxman A, Naghavi M, et al. Years lived with disability (YLDs) for 1160 sequelae of 289 diseases and injuries 1990-2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet. 2012;380(9859): 2163-2196.
6. Co?te? P, Cassidy JD, Carroll L. The treatment of neck and low back pain: who seeks care? Who goes where? Med Care. 2001;39(9):956-967.
7. Hoy DG, Protani M, De R, Buchbinder R. The epidemi- ology of neck pain. Best Pract Res Clin Rheumatol. 2010; 24(6):783-792.
8. Murray C, Abraham J, Ali M, et al. The state of us health, 1990-2010: burden of diseases, injuries, and risk factors. JAMA. 2013;310(6):591-606.
9. Manchikanti L, Singh V, Datta S, Cohen S, Hirsch J. Physicians. ASoIP. Comprehensive review of epidemiolo- gy, scope, and impact of spinal pain. Pain Physician. 2009; 12(4):E35-E70.
10. Hincapie? C, Cassidy J, Co?te? P, Carroll L, Guzma?n J. Whiplash injury is more than neck pain: a population-based study of pain localization after traffic injury. J Occup Environ Med. 2010;52(4):434-440.
11. Blincoe L, Miller T, Zaloshnja E, Lawrence B. The Economic and Societal Impact of Motor Vehicle Crashes, 2010. (Revised) (Report No. DOT HS 812 013). Washington, DC: National Highway Traffic Safety Administration; 2015.
12. Bannister G, Amirfeyz R, Kelley S, Gargan M. Whiplash injury. J Bone Joint Surg. 2009;91-B(7):845-850.
13. Johansson M, Boyle E, Hartvigsen J, Carroll L, Cassidy J. A population-based, incidence cohort study of mid-back pain after traffic collisions: factors associated with global recovery. EuroJ Pain. 2015;19(10):186-195.
14. Styrke J, Stalnacke B, Bylund P, Sojka P. A 10-year incidence of acute whiplash injuries after road traffic crashes in a defined population in northern Sweden. PM R. 2012;4(10):739-747.
15. Ontario MoFo. Ontario Auto Insurance Anti-Fraud Task Force Interim Report. Available at: http://www.fin.gov.on. ca/en/autoinsurance/interim-report.pdf Accessed May 7, 2016.
16. Karlsborg M, Smed A, Jespersen H, et al. A prospective study of 39 patients with whiplash injury. Acta Neurol Scand. 1997;95(2):65-72.
17. Sterling M, Jull G, Vicenzino B, Kenardy J, Darnell R. Development of motor system dysfunction following whiplash injury. Pain. 2003;103(1-2):65-73.
18. Guzman J, Hurwitz EL, Carroll LJ, et al. A new conceptual model of neck pain: linking onset, course, and care: the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders. Spine. 2008;33(4 Suppl): S14-S23.
19. Leaver A, Maher C, McAuley J, Jull G, Refshauge K. Characteristics of a new episode of neck pain. Man Ther. 2013;18(3):254-257.
20. Co?te? P, Shearer H, Ameis A, et al. Enabling recovery from common traffic injuries: a focus on the injured person. UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation; 2015.
21. Clar C, Tsertsvadze A, Court R, Hundt G, Clarke A, Sutcliffe P. Clinical effectiveness of manual therapy for the management of musculoskeletal and non-musculoskeletal conditions: systematic review and update of UK evidence report. Chiropract Man Ther. 2014;22(1):12.
22. Bronfort G, Evans R, Anderson A, Svendsen K, Bracha Y, Grimm R. Spinal manipulation, medication, or home exercise with advice for acute and subacute neck pain. Ann Intern Med. 2012;156(1 Part 1):1-10.
23. Hurwitz EL, Carragee EJ, van der Velde G, et al. Treatment of neck pain: noninvasive interventions. Results of the Bone and Joint Decade 2000�2010 Task Force on Neck Pain and its Associated Disorders. Spine. 2008;33(4S):S123-S152.
24. Bryans R, Decina P, Descarreaux M, et al. Evidence-based guidelines for the chiropractic treatment of adults with neck pain. J Manip Physiol Therap. 2014;37(1):42-63.
25. Shaw L, Descarreaux M, Bryans R, et al. A systematic review of chiropractic management of adults with whiplash- associated disorders: recommendations for advancing evidence-based practice and research. Work. 2010;35(3): 369-394.
26. Graham G, Mancher M, Miller Wolman D, Greenfield S, Steinberg E, editors. Clinical Practice Guidelines We Can Trust. Institute of Medicine, Shaping the Future for Health.
Washington, DC: National Academies Press; 2011.
27. Co?te? P, Wong JJ, Sutton D, et al. Management of neck pain and associated disorders: a clinical practice guideline from the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration. Euro Spine J. 2016;25(7): 2000-2022.
28. Johnson AP, Sikich NJ, Evans G, et al. Health technology assessment: a comprehensive framework for evidence- based recommendations in ontario. Int J Technol Assess Health Care. 2009;25(2):141-150.
29. Shukla V, Bai A, Milne S, Wells G. Systematic review of the evidence grading system for grading level of evidence. German J Evid Qual Health Care. 2008; 102:43.
30. Mustafa RA, Santesso N, Brozek J, et al. The GRADE approach is reproducible in assessing the quality of evidence of quantitative evidence syntheses. J Clin Epidemiol. 2013;66(7):736-742.e5.
31. Woolf S, Schunemann H, Eccles M, Grimshaw J, Shekelle P. Developing clinical practice guidelines: types of evidence and outcomes; values and economics, synthesis, grading, and presentation and deriving recommendations. lImplementation Sci. 2012;7(1):61.
32. Tricco A, Tetzlaff J, Moher D. The art and science of knowledge synthesis. J Clin Epidemiol. 2011;64(1):11-20.
33. Guyatt G, Eikelboom JW, Akl EA, et al. A guide to GRADE
guidelines for the readers of JTH. J Thromb Haemost. 2013;
11(8):1603-1608.
34. Adaptation. The ADAPTE Manual and Resource
Toolkit V2. G-I-N Adaptation Working Group. Available at: http://www.g-i-n.net/working-groups/adaptation Accessed May 16, 2016.
35. Brouwers M, Kho M, Browman G, et al. AGREE II: advancing guideline development, reporting and evalua- tion in health care. J Clin Epidemiol. 2010;63(12): 1308-1311.
36. Flottorp S, Oxman AD, Cooper JG, Hjortdahl P, Sandberg S, Vorland LH. Retningslinjer for diagnostikk og behand- ling av sar hals. Tidsskr Nor Laegeforen. 2000;120: 1754-1760.
37. Grimshaw J, Eccles M, Lavis J, Hill S, Squires J. Knowledge translation of research findings. Implementation Sci. 2012;7(1):50.
38. Southerst D, Nordin M, Co?te? P, et al. Is exercise effective for the management of neck pain and associated disorders or whiplash-associated disorders? A systematic review by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration. Spine J. 2014;S1529-1530(14): 00210-1.
39. Sutton D, Cote P, Wong J, et al. Is multimodal care effective for the management of patients with whiplash-associated disorders or neck pain and associated disorders? A systematic review by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration. Spine J. 2014 [S1529-9430(14):00650-0].
40. Yu H, Co?te? P, Southerst D, Wong J, et al. Does structured patient education improve the recovery and clinical outcomes of patients with neck pain? A systematic review from the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration. Spine J. 2014;pii: S1529- 9430(14).
41. Varatharajan S, Co?te? P, Shearer H, et al. Are work disability prevention interventions effective for the management of neck pain or upper extremity disorders? A systematic review by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration. J Occup Rehabil. 2014;24(4): 692-708.
42. Wong JJ, Shearer HM, Mior S, et al. Are manual therapies, passive physical modalities, or acupuncture effective for the management of patients with whiplash-associated disorders or neck pain and associated disorders? An update of the Bone and Joint Decade Task Force on Neck Pain and Its Associated Disorders by the Optima Collaboration. Spine J. 2015;20(8 Suppl).
43. Shea B, Grimshaw J, Wells G, Boers M, Andersson N, Hamel C. Development of AMSTAR: a measurement tool to assess the methodological quality of systematic reviews. BMC Med Res Methodol. 2007;7:10.
44. Norman G, Streiner D. Biostatistics: The Bare Essentials. 3rd ed. Hamilton, ON: BC Decker; 2008.
45. Ricci S, Celani M, Righetti E. Development of clinical guidelines: methodological and practical issues. Neurol Sci. 2006;27(Suppl 3):S228-S230.
46. van der Velde G, van Tulder M, Co?te? P, et al. The sensitivity of review results to methods used to appraise and incorporate trial quality into data synthesis. Spine. 2007; 32(7):796-806.
47. Slavin R. Best evidence synthesis: an intelligent alternative to meta-analysis. J Clin Epidemiol. 1995;48(1):9-18.
48. Network GI, GRADE Working Group. Resources. Available at: http://www.g-i-n.net/working-groups/updating-guidelines/re- sources. Accessed May 5, 2016.
49. Guyatt G, Oxman A, Vist G, et al. GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. BMJ. 2008;336(7650):924-926.
50. Guyatt G, Oxman A, Akl E, Kunz R, Vist G, Brozek J, et al. GRADE guidelines 1. Introduction: GRADE evidence profiles and summary of findings tables. J Clin Epidemiol. 2011;64(4):38-94.
51. Treweek S, Oxman A, Alderson P, et al. Developing and evaluating communication strategies to support informed decisions and practice based on evidence (DECIDE): protocol and preliminary results. Implementation Sci. 2013; 8(1):6.
52. McCarthy M, Grevitt M, Silcocks P, Hobbs G. The reliability of the Vernon and Mior neck disability index, and its validity compared with the short form-36 health survey questionnaire. Eur Spine J. 2007;16(12):2111-2117.
53. Stauffer M, Taylor S, Watson D, Peloso P, Morrison A. Definition of nonresponse to analgesic treatment of arthritic pain: an analytical literature review of the smallest detectable difference, the minimal detectable change, and the minimal clinically important difference on the pain visual analog scale. Int J Inflam. 2011;2011:231926.
54. Hawker GA, Mian S, Kendzerska T, French M. Measures of adult pain: visual analog scale for pain (VAS Pain), numeric rating scale for pain (NRS Pain), McGill Pain Questionnaire (MPQ), Short-Form McGill Pain Questionnaire (SF-MPQ), Chronic Pain Grade Scale (CPGS), Short Form-36 Bodily Pain Scale (SF-36 BPS), and Measure of Intermittent and Constant Osteoarthritis Pain (ICOAP. Arthritis Care Res. 2011;63(S11):S240-S252.
55. Blozik E, Himmel W, Kochen MM, Herrmann-Lingen C, Scherer M. Sensitivity to change of the Neck Pain and Disability Scale. Euro Spine J. 2011;20(6):882-889.
56. Andrews J, Guyatt G, Oxman AD, et al. GRADE guidelines: 14. Going from evidence to recommendations: the signifi- cance and presentation of recommendations. J Clin Epidemiol. 2013;66(7):719-725.
57. Andrews JC, Schu?nemann HJ, Oxman AD, et al. GRADE guidelines: Going from evidence to recommendation� determinants of a recommendation’s direction and strength. J Clinl Epidemiol. 2013;66(7):726-735.
58. Black N, Murphy M, Lamping D, McKee M, Sanderson C, Askham J. Consensus development methods: a review of best practice in creating clinical guidelines. J Health Serv Res Policy. 1999;4(4):236-248.
59. Seo H-J, Kim KU. Quality assessment of systematic reviews or meta-analyses of nursing interventions conducted by Korean reviewers. BMC Med Res Methodol. 2012;12:129.
60. Leaver A, Maher C, Herbert R, et al. A randomized controlled trial comparing manipulation with mobilization for recent onset neck pain. Arch Phys Med Rehabil. 2010;91(9):1313-1318.
61. Dunning J, Cleland J, Waldrop M, et al. Upper cervical and upper thoracic thrust manipulation versus nonthrust mobiliza- tion in patients with mechanical neck pain: a multicenter randomized clinical trial. J Orthop Sports Phys Ther. 2012; 42(1):5-18.
62. Nagrale A, Glynn P, Joshi A, Ramteke G. The efficacy of an integrated neuromuscular inhibition technique on upper trapezius trigger points in subjects with non-specific neck pain: a randomized controlled trial. J Man Manip Ther. 2010; 18(1):37-43.
63. McReynolds T, Sheridan B. Intramuscular ketorolac versus osteopathic manipulative treatment in the management of acute neck pain in the emergency department: a randomized clinical trial. JAOA. 2005;105(2):57-68.
64. Chou R, Turner JA, Devine EB, et al. The effectiveness and risks of long-term opioid therapy for chronic pain: a systematic review for a National Institutes of Health Pathways to Prevention Workshop Effectiveness and Risks of Long-Term Opioid Therapy for Chronic Pain. Ann Inter Med. 2015;162(4):276-286.
65. Kuijper B, Tans J, Beelen A, Nollet F, de Visser M. Cervical collar or physiotherapy versus wait and see policy for recent onset cervical radiculopathy: randomised trial. BMJ. 2009;339:b3883.
66. Cassidy J. Mobilisation or immobilisation for cervical radiculo- pathy? BMJ. 2009;339(b):3952.
67. Konstantinovic L, Cutovic M, Milovanovic A, et al. Low-level laser therapy for acute neck pain with radiculopathy: a double- blind placebo-controlled randomized study. Pain Med. 2010; 11(8):1169-1178.
68. van den Heuvel S, de Looze M, Hildebrandt V, The? K. Effects of software programs stimulating regular breaks and exercises on work-related neck and upper-limb disorders. Scand J Work Environ Health. 2003;29(2):106-116.
69. Lamb S, Gates S, Williams M, et al. Emergency department treatments and physiotherapy for acute whiplash: a pragmatic, two-step, randomised controlled trial. Lancet. 2013;381(9866): 546-556.
70. Ferrari R, Rowe BH, Majumdar SR, et al. Simple educational intervention to improve the recovery from acute whiplash: results of a randomized, controlled trial. Acad Emerg Med. 2005;12(8): 699-706.
71. von Trott P, Wiedemann A, Lu?dtke R, Rei�hauer A, Willich S, Witt C. Qigong and exercise therapy for elderly patients with chronic neck pain (QIBANE): a randomized controlled study. J Pain. 2009;10(5):501-508.
72. Rendant D, Pach D, Ludtke R, et al. Qigong versus exercise versus no therapy for patients with chronic neck pain: a randomized controlled trial. Spine. 2011;36(6):419-427.
73. Michalsen A, Traitteur H, Lu?dtke R, et al. Yoga for chronic neck pain: a pilot randomized controlled clinical trial. J Pain. 2012; 13(11):1122-1130.
74. Jeitler M, Brunnhuber S, Meier L, et al. Effectiveness of jyoti meditation for patients with chronic neck pain and psychological distress-a randomized controlled clinical trial. J Pain. 2015;16(1): 77-86.
75. Hakkinen A, Kautiainen H, Hannonen P, Ylinen J. Strength training and stretching versus stretching only in the treatment of patients with chronic neck pain: a randomized one-year follow-up
study. Clin Rehabil. 2008;22(7):593-600.
76. Salo P, Ylonen-Kayra N, Hakkinen A, Kautiainen H, Malkia E,
Ylinen J. Effects of long-term home-based exercise on health- related quality of life in patients with chronic neck pain: a randomized study with a 1-year follow-up. Disabil Rehabil. 2012; 34(23):1971-1977.
77. Evans R, Bronfort G, Schulz G, et al. Supervised exercise with and without spinal manipulation performs similarly and better than home exercise for chronic neck pain: a randomized controlled trial. Spine. 2012;37(11):903-914.
78. Maiers M, Bronfort G, Evans R, et al. Spinal manipulative therapy and exercise for seniors with chronic neck pain. Spine J. 2014;14(9):1879-1889.
79. Griffiths C, Dziedzic K, Waterfield J, Sim J. Effectiveness of specific neck stabilization exercises or a general neck exercise program for chronic neck disorders: a randomized controlled trial. J Rheumatol. 2009;36(2):390-397.
80. Gustavsson C, Denison E, von Koch L. Self-management of persistent neck pain: a randomized controlled trial of a multi- component group intervention in primary health care. Eur J Pain. 2010;14(6):630.e1-11.
81. Gustavsson C, Denison E, von Koch L. Self-management of persistent neck pain: two-year follow-up of a randomized controlled trial of a multicomponent group intervention in primary health care. Spine. 2011;36(25):2105-2115.
82. Sherman K, Cherkin D, Hawkes R, Miglioretti D, Deyo R. Randomized trial of therapeutic massage for chronic neck pain. Clin J Pain. 2009;25(3):233-238.
83. Lin J, Shen T, Chung R, Chiu T. The effectiveness of Long’s manipulation on patients with chronic mechanical neck pain: a randomized controlled trial. Manual Ther. 2013;18(4):308-315.
84. Lauche R, Materdey S, Cramer H, et al. Effectiveness of home- based cupping massage compared to progressive muscle relaxation in patients with chronic neck pain�a randomized controlled trial. PLoS One. 2013;8(6):e65378.
85. Sherman K, Cook A, Wellman R, et al. Five-week outcomes from a dosing trial of therapeutic massage for chronic neck pain. Ann Fam Med. 2014;12(2):112-120.
86. Walker MJ, Boyles RE, Young BA, et al. The effectiveness of manual physical therapy and exercise for mechanical neck pain: a randomized clinical trial. Spine (Phila Pa 1976). 2008;33(22): 2371-2378.
87. Boyles R, Walker M, Young B, Strunce J, Wainner R. The addition of cervical thrust manipulations to a manual physical therapy approach in patients treated for mechanical neck pain: a secondary analysis. J Orthop Sports Phys Ther. 2010;40(3): 133-140.
88. Hoving JL, de Vet HC, Koes BW, et al. Manual therapy, physical therapy, or continued care by the general practitioner for patients with neck pain: long-term results from a pragmatic randomized clinical trial. Clin J Pain. 2006;22(4):370-377.
89. Hoving JL, Koes BW, de Vet HCW, et al. Manual Therapy, physical therapy, or continued care by a general practitioner for patients with neck pain: a randomized, controlled trial. Ann Intern Med. 2002;136(10):713-722.
90. Monticone M, Baiardi P, Vanti C, et al. Chronic neck pain and treatment of cognitive and behavioural factors: results of a randomised controlled clinical trial. Euro Spine J. 2012;21(8): 1558-1566.
91. Zebis M, Andersen L, Pedersen M, et al. Implementation of neck/shoulder exercises for pain relief among industrial workers: a randomized controlled trial. BMC Musculoskelet Disord. 2011;12:205.
92. Zebis MK, Andersen CH, Sundstrup E, Pedersen MT, Sj�gaard G, Andersen LL. Time-wise change in neck pain in response to rehabilitation with specific resistance training: implications for
exercise prescription. PLoS One. 2014;9(4):e93867.
93. Andersen C, Andersen L, Gram B, et al. Influence of frequency and duration of strength training for effective management of neck and shoulder pain: a randomised controlled trial. Br J
Sports Med. 2012;46(14):1004-1010.
94. Andersen L, Jorgensen M, Blangsted A, Pedersen M, Hansen E,
Sjogaard GA. randomized controlled intervention trial to relieve and prevent neck/shoulder pain. Med Sci Sports Exerc. 2008; 40(6):983-990.
95. Sjogren T, Nissinen K, Jarvenpaa S, Ojanen M, Vanharanta H, Malkia E. Effects of a workplace physical exercise intervention on the intensity of headache and neck and shoulder symptoms and upper extremity muscular strength of office workers: a cluster randomized controlled cross-over trial. Pain. 2005;116(1-2):119-128.
96. Stewart M, Maher C, Refshauge K, Herbert R, Bogduk N, Nicholas M. Randomized controlled trial of exercise for chronic whiplash-associated disorders. Pain. 2007;128(1-2):59-68.
97. Michaleff Z, Maher C. Lin C-WC, et al. Comprehensive physiotherapy exercise programme or advice for chronic whiplash (PROMISE): a pragmatic randomised controlled trial. Lancet. 2014;384(9938):133-141.
98. Gram B, Andersen C, Zebis MK, et al. Effect of training supervision on effectiveness of strength training for reducing neck/shoulder pain and headache in office workers: cluster randomized controlled trial. BioMed Ress Int. 2014;2014:9.
99. Jull G, Sterling M, Kenardy J, Beller E. Does the presence of sensory hypersensitivity influence outcomes of physical reha- bilitation for chronic whiplash? A preliminary RCT. Pain. 2007; 129(1-2):28-34.
100. Jull G, Kenardy J, Hendrikz J, Cohen M, Sterling M. Management of acute whiplash: a randomized controlled trial of multidisciplin- ary stratified treatments. Pain. 2013;154(9):1798-1806.
101. Wiangkham T, Duda J, Haque S, Madi M, Rushton A. The effectiveness of conservative management for acute whiplash associated disorder (WAD) II: a systematic review and meta- analysis of randomised controlled trials. PLoS One. 2015;10(7): e0133415.
102. Guyatt G, Oxman AD, Sultan S, et al. GRADE guidelines: 11. Making an overall rating of confidence in effect estimates for a single outcome and for all outcomes. J Clin Epidemiol. 2013; 66(2):151-157.
103. Walsh D, Howe T, Johnson M, Sluka K. Transcutaneous electrical nerve stimulation for acute pain. Cochrane Database Syst Rev. 2009(2)CD006142.
104. Nnoaham K, Kumbang J. Transcutaneous electrical nerve stimulation (TENS) for chronic pain. Cochrane Database Syst Rev. 2008(3)CD003222.
105. French S, Cameron M, Walker B, Reggars J, Esterman A. Superficial heat or cold for low back pain. Cochrane Database Syst Rev. 2006(1)CD004750.
106. Malanga GA, Yan N, Stark J. Mechanisms and efficacy of heat and cold therapies for musculoskeletal injury. Postgrad Med. 2015;127(1):57-65.
107. Carnes D, Mullinger B, Underwood M. Defining adverse events in manual therapies: a modified Delphi consensus study. lManual Ther. 2010;15(1):2-6.
108. Haldeman S, Carroll LJ, Cassidy JD. The empowerment of people with neck pain: introduction: the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders. Spine. 2008;33(4 Suppl):S8-S13.
109. Maiers M, Vihstadt C, Hanson L, Evans R. Perceived value of spinal manipulative therapy and exercise among seniors with chronic neck pain: a mixed methods study. J Rehabil Med. 2014;46(10):1022-1028.
110. Chou R, Deyo R, Friedly J, et al. Noninvasive treatments for low back pain. Comparative Effectiveness Review No. 169. (Prepared by the Pacific Northwest Evidence-based Practice Center under Contract No. 290-2012-00014-I.). AHRQ Publication No. 16-EHC004-EF. Rockville, MD. Available at: www.effectivehealthcare.ahrq.gov/reports/final.cfm. Accessed May 15, 2016.
111. Machado G, Maher C, Ferreira P, et al. Efficacy and safety of paracetamol for spinal pain and osteoarthritis: systematic review and meta-analysis of randomised placebo controlled trials. BMJ. 2015;350:h1225.
112. Miller M, Barber CW, Leatherman S, et al. Prescription opioid duration of action and the risk of unintentional overdose among patients receiving opioid therapy. JAMA Intern Med. 2015; 175(4):608-615.
113. Volkow N, McLellan A. Opioid abuse in chronic pain� misconceptions and mitigation strategies. N Engl J Med. 2016; 374(13):1253-1263.
114. Foster N, Hartvigsen J, Croft P. Taking responsibility for the early assessment and treatment of patients with musculoskeletal pain: a review and critical analysis. Arthritis Res Ther. 2012;14(1):205.
115. World Health Organization. WHO Guidelines on Basic Training and Safety in Chiropractic. Geneva, Switzerland: World Health Organization; 2005.
116. Guzman J, Haldeman S, Carroll L, et al. Clinical practice implications of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders: from concepts and findings to recommendations. Spine. 2008;33(4 Suppl):S199-S213.
117. Dietl M, Korczak D. Over-, under- and misuse of pain treatment in Germany. GMS Health Technol Assess. 2011; 7:Doc03. http://dx.doi.org/10.3205/hta000094.
118. Freburger J, Carey T, Holmes G, Wallace A, Castel L, Darter J. Exercise prescription for chronic back or neck pain: who prescribes it? Who gets it? What is prescribed? lArthritis Care Res. 2009;61:192-200.
119. Goode A, Freburger J, Carey T. Prevalence, practice patterns, and evidence for chronic neck pain. Arthritis Care Res. 2010;62(11):1594-1601.
120. Kamaleri Y, Natvig B, Ihlebaek CM, Bruusgaard D. Localized or widespread musculoskeletal pain: does it matter? Pain. 2008;138(1):41-46.
121. MacDermid J, Miller J, Gross A. Knowledge translation tools are emerging to move neck pain research into practice. lOpen Orthop J. 2013;20(7):582-593.
122. Medina-Mirapeix F, Escolar-Reina P, Gascon-Canovas J, Montilla-Herrador J, Jimeno-Serrano F, Collins S. Predictive factors of adherence to frequency and duration components in home exercise programs for neck and low back pain: an observational study. BMC Musculoskelet Disord. 2009;10(1):155.
123. Kay T, Gross A, Goldsmith C, et al. Exercises for mechanical neck disorders. Cochrane Database Syst Rev. 2012;8:CD004250.
124. Bertozzi L, Gardenghi I, Turoni F, et al. Effect of
therapeutic exercise on pain and disability in the manage- ment of chronic nonspecific neck pain: systematic review and meta-analysis of randomized trials. Phys Ther. 2013; 93(8):1026-1036.
125. Hartvigsen J, Natvig B, Ferreira M. Is it all about a pain in the back? Best Pract Res Clin Rheumatol. 2013;27(5):613-623.
126. Ambrose K, Golightly Y. Physical exercise as non-pharmaco- logical treatment of chronic pain: why and when. Best Pract Res Clin Rheumatol. 2015;29(1):120-130.
127. Lee I, Shiroma E, Lobelo F, Puska P, Blair S, Katzmarzyk P. Effect of physical inactivity on major non-communicable diseases worldwide: an analysis of burden of disease and life expectancy. Lancet. 2012;380(9838):219-229.
128. World Health Organization. Global Recommendations on Physical Activity for Health. Geneva, Switzerland: World Health Organization; 2010.
129. Carroll LJ, Ferrari R, Cassidy JD, Cote P. Coping and recovery in whiplash-associated disorders: early use of passive coping strategies is associated with slower recovery of neck pain and pain-related disability. Clin J Pain. 2014;30(1):1-8.
130. Gore M, Sadosky A, Stacey B, Tai K, Leslie D. The burden of chronic low back pain: clinical comorbidities, treatment patterns, and health care costs in usual care settings. Spine. 2012;37(11):E668-E677.
131. Bodenheimer T, MacGregor K, Charifi C. Helping patients manage their chronic conditions. Oakland, CA: California HealthCare Foundation; 2005.
132. Ritzwoller D, Crounse L, Shetterly S, Rublee D. The association of comorbidities, utilization and costs for patients identified with low back pain. BMC Musculoskelet Disord. 2006;7(1):72.
133. Sallis R, Franklin B, Joy L, Ross R, Sabgir D, Stone J. Strategies for promoting physical activity in clinical practice. Prog Cardiovasc Dis. 2015;57(4):375-386.
134. Von Korff M, Crane P, Lane M, et al. Chronic spinal pain and physical-mental comorbidity in the United States: results from the national comorbidity survey replication. Pain. 2005;113(3): 331-339.
135. Bussie?res A, Al Zoubi F, Quon J, et al. Fast tracking the design of theory-based KT interventions through a consensus process. Implementation Sci. 2015;10(1):18.
136. Gutnick D, Reims K, Davis C, Gainforth H, Jay M, Cole S. Brief action planning to facilitate behavior change and support patient self-management. J Clin Outcomes Manag. 2014;21: 17-29.
137. Dhopte P, Ahmed S, Mayo N, French S, Quon JA, Bussie?res A. Testing the feasibility of a knowledge translation intervention designed to improve chiropractic care for adults with neck pain disorders: study protocol for a pilot cluster-randomized controlled trial. Pilot and Feasibility Studies. 2016;2(1):1-11.
138. Turner L, Shamseer L, Altman D, et al. Consolidated standards of reporting trials (CONSORT) and the complete- ness of reporting of randomised controlled trials (RCTs) published in medical journals. Cochrane Database Syst Rev. 2012;11:MR000030.
139. Quinlan K, Annest J, Myers B, Ryan G, Hill H. Neck strains and sprains among motor vehicle occupants�United States, 2000. Accid Anal Prev. 2004;36(1):21-27.
140. Titler M. The evidence for evidence-based practice imple- mentation. Patient Safety and Quality: An Evidence-Based Handbook for Nurses, vol. 1. Rockville, MD: AHRQ; 2008. p. 113-161.
141. The Canadian Agency for Drugs and Technologies in Health. Rx for Change database. Available at: https://www.cadth.ca/rx-change. Accessed May 6, 2016.
142. Grimshaw J, Thomas R, MacLennan G, Fraser C, Ramsay C, Vale L. Effectiveness and efficiency of guideline dissemina- tion and implementation strategies. Health Technol Assess. 2004;8(6):1-72.
143. Bishop PB, Quon JA, Fisher CG, Dvorak MFS. The Chiropractic Hospital-based Interventions Research Outcomes (CHIRO) Study: a randomized controlled trial on the effectiveness of clinical practice guidelines in the medical and chiropractic management of patients with acute mechanical low back pain. Spine J. 2010;10(12):1055-1064.
144. Grimshaw J, Schunemann H, Burgers J, Cruz A, Heffner J, Metersky M. Disseminating and implementing guidelines. Article 13 in integrating and coordinating efforts in COPD guideline development. Proc Am Thorac Soc. 2012;9(5): 298-303.
145. Pronovost P. Enhancing physicians’ use of clinical guide- lines. JAMA. 2013;310(23):2501-2502.
146. Schuster, MA, Elizabeth A, McGlynn R, Brook H. How good is the quality of health care in the United States? Milbank. 2005;83(4):843-895.
147. Greenhalgh T, Howick J, Maskrey N. Evidence based medicine: a movement in crisis? BMJ. 2014;348:g3725. 148. Canadian Institutes of Health Research. Knowledge translation�
definition. 2008 Available at: http://www.cihr-irsc.gc.ca/e/29529.html.
Accessed May 6, 2016.
149. Gagliardi A, Marshall C, Huckson S, James R, Moore V.
Developing a checklist for guideline implementation planning: review and synthesis of guideline development and implemen- tation advice. Implementation Sci. 2015;10(1):19.
150. Cochrane-Effective Practice and Organisation of Care (EPOC). Available at: http://epoc.cochrane.org/our-reviews. Accessed May 6, 2016.
151. Gagliardi A, Brouwers M, Bhattacharyya O. A framework of the desirable features of guideline implementation tools (GItools): Delphi survey and assessment of GItools. Implementation Sci. 2014;9(1):98.
152. Okelo S, Butz A, Sharma R, et al. Interventions to modify health care provider adherence to asthma guidelines: a systematic review. Pediatrics. 2013;132(3):517-534.
153. Murthy L, Shepperd S, Clarke M, et al. Interventions to improve the use of systematic reviews in decision-making by health system managers, policy makers and clinicians. Cochrane Database Syst Rev. 2012;9CD009401.
154. Garg A, Adhikari N, McDonald H, et al. Effects of computerized clinical decision support systems on practitioner performance and patient outcomes: a systematic review. JAMA. 2005; 293(10):1223-1238.
155. Rebbeck T, Macedo L, Maher C. Compliance with clinical guidelines for whiplash improved with a targeted implemen- tation strategy: a prospective cohort study. BMC Health Serv Res. 2013;13(1):213.
156. Bussie?res A, Co?te? P, French S, et al. Creating a chiropractic practice-based research network (PBRN): enhancing the management of musculoskeletal care. J Can Chiropr Assoc. 2014;58(1):8-15.
157. Canadian Chiropractic Research Database (CCRD). National Report. The Canadian Chiropractic Association: A Compre- hensive Inventory of Practical Information About Canada�s Licensed Chiropractors; 2011.
158. Becker M, Neugebauer E, Eikermann M. Partial updating of clinical practice guidelines often makes more sense than full updating: a systematic review on methods and the development of an updating procedure. J Clin Epidemiol. 2014;67(1):33-45.
159. Alonso-Coello P, Marti?nez Garci?a L, Carrasco JM, Sola? I, Qureshi S, Burgers JS. The updating of clinical practice guidelines: insights from an international survey. Implementation Sci. 2011;6(1):1-8.
160. Marti?nez Garci?a L, Are?valo-Rodri?guez I, Sola? I, Haynes R, Vandvik P, Alonso-Coello P. Strategies for monitoring and updating clinical practice guidelines: a systematic review. Implementation Sci. 2012;7(1):1-10.
161. Moher D, Tsertsvadze A, Tricco A, et al. A systematic review identified few methods and strategies describing when and how to update systematic reviews. J Clin Epidemiol. 2007;60(11):1095. e1-11.
162. Shekelle P, Eccles M, Grimshaw J, Woolf S. When should clinical guidelines be updated? BMJ. 2001;323(7305):155-157.
163. Vernooij R, Sanabria A, Sola I, Alonso-Coello P, Martinez Garcia L. Guidance for updating clinical practice guidelines: a systematic review of methodological handbooks. Implement Sci. 2014;9:3.
164. Moher D, Pham B, Lawson M, Klassen T. The inclusion of reports of randomised trials published in languages other than English in systematic reviews. Health Technol Assess. 2003; 7(41):1-90.
165. Morrison A, Polisena J, Husereau D, et al. The effect of English-
language restriction on systematic review-based meta-analyses: a
systematic review of empirical studies. Int J Technol Assess
Health Care. 2012;28(20120426):138-144.
166. Harbour R, Miller JA. new system for grading recommen- dations in evidence based guidelines. BMJ. 2001;323(7308): 334-336.
167. Cleland J, Mintken P, Carpenter K, et al. Examination of a clinical prediction rule to identify patients with neck pain likely to benefit from thoracic spine thrust manipulation and a general cervical range of motion exercise: multi-center randomized clinical trial. Phys Ther. 2010;90(9):1239-1250.
168. Escortell-Mayor E, Riesgo-Fuertes R, Garrido-Elustondo S, et al. Primary care randomized clinical trial: Manual therapy effectiveness in comparison with TENS in patients with neck pain. Man Ther. 2011;16(1):66-73.
169. Lamb S, Williams M, Williamson E, et al. Managing Injuries of the Neck Trial (MINT): a randomised controlled trial of treatments for whiplash injuries. Health Technol Assess. 2012; 16(49:iii-iv):1-141.
170. Pool J, Ostelo R, Knol D, Vlaeyen J, Bouter L, de Vet HI. a behavioral graded activity program more effective than manual therapy in patients with subacute neck pain?: results of a randomized clinical trial. Spine. 2010;35(10): 1017-1024.
171. Skillgate E, Bohman T, Holm L, Vinga?rd E, Alfredsson L. The long-term effects of naprapathic manual therapy on back and neck pain. Results from a pragmatic randomized controlled trial. BMC Musculoskelet Disord. 2010;11(1): 1-11.
172. Kongsted A, Qerama E, Kasch H, et al. Education of patients after whiplash injury: is oral advice any better than a pamphlet? Spine. 2008;33(22):E843-E848.
173. Andersen L, Saervoll C, Mortensen O, Poulsen O, Hannerz H, Zebis M. Effectiveness of small daily amounts of progressive resistance training for frequent neck/shoulder pain: Rando- mised controlled trial. Pain. 2011;152(2):440-446.
174. Cheng A, Hung L. Randomized controlled trial of workplace- based rehabilitation for work-related rotator cuff disorder. lJ Occup Rehab. 2007;17(3):487-503.
175. Feuerstein M, Nicholas R, Huang G, Dimberg L, Ali D, Rogers H. Job stress management and ergonomic interven- tion for work-related upper extremity symptoms. Appl Ergon. 2004;35(6):565-574.
176. van Eijsden-Besseling M, Bart Staal J, van Attekum A, de Bie RA, van den Heuvel W. No difference between postural exercises and strength and fitness exercises for early, non- specific, work-related upper limb disorders in visual display unit workers: a randomised trial. Aust J Physiother. 2008; 54(2):95-101.
177. Cameron I, Wang E, Sindhusake DA. randomized trial comparing acupuncture and simulated acupuncture for subacute and chronic whiplash. Spine. 2011;36(26):E1659-E1665.
178. Cleland JA, Glynn PE, Whitman JM, et al. Short-term response of thoracic spine thrust versus non-thrust manipulation in patients with mechanical neck pain: preliminary analysis of a randomized clinical trial. J Manual Manipulat Ther. 2007;14: 172
179. Dundar U, Evcik D, Samli F, Pusak H, Kavuncu V. The effect of gallium arsenide aluminum laser therapy in the management of cervical myofascial pain syndrome: a double blind, placebo- controlled study. Clin Rheumatol. 2007;26(6):930-934.
180. Fu W, Zhu X, Yu P, Zhang J. Analysis on the effect of acupuncture in treating 5 cervical spondylosis with different syndrome types. Chin J Integr Med. 2009;15(6):426-430.
181. Kanlayanaphotporn R, Chiradejnant A, Vachalathiti R. The immediate effects of mobilization technique on pain and range of motion in patients presenting with unilateral neck pain: a randomized controlled trial. Arch Phys Med Rehabil. 2009; 90(2):187-192.
182. Kanlayanaphotporn R, Chiradejnant A, Vachalathiti R. Immediate effects of the central posteroanterior mobiliza- tion technique on pain and range of motion in patients with mechanical neck pain. Dis Rehab. 2010;32(8): 622-628.
183. Klein R, Bareis A, Schneider A, Linde K. Strain-counter- strain to treat restrictions of the mobility of the cervical spine in patients with neck pain: a sham-controlled randomized trial. Complement Ther Med. 2013;21(1):1-7.
184. Liang Z, Zhu X, Yang X, Fu W, Lu A. Assessment of a traditional acupuncture therapy for chronic neck pain: a pilot randomised controlled study. Complementary Ther Med. 2011; 19(Suppl 1):S26-S32.
185. Masaracchio M, Cleland JA, Hellman M, Hagins M. Short-term combined effects of thoracic spine thrust manipulation and cervical spine nonthrust manipulation in individuals with mechanical neck pain: a randomized clinical trial. J Orthop Sports Phys. 2013;43(3):118-127.
186. Saavedra-Hernandez M, Castro-Sanchez A, Arroyo-Morales M, et al. Short term effects of kinesio taping versus cervical thrust manipulation in patients with mechanical neck pain: a randomized clinical trial. J Orthop Sports Phys Ther. 2012;42: 724-730.
187. Sillevis R, Hellman M, Beekhuizen K. Immediate effects of a thoracic spine thrust manipulation on the autonomic nervous system: a randomized clinical trial. J Manual Manipulat Ther. 2010;18:181-190.
188. White P, Lewith G, Prescott P, Conway J. Acupuncture versus placebo for the treatment of chronic mechanical neck pain: a randomized, controlled trial. Ann Inter Med. 2004;141(12): 911-919.
189. Young I, Cleland J, Aguilera A, et al. Manual therapy, exercise, and traction for patients with cervical radiculopathy: a randomized clinical trial. Phys Ther. 2009;89:632-642.

Close Accordion
Chronic Neck Pain | Understanding Cervical Instability

Chronic Neck Pain | Understanding Cervical Instability

Being involved in an automobile accident can cause damage or injury to the complex structures of the cervical spine which can go unnoticed for months if left untreated. Medically referred to as whiplash-associated disorders, or whiplash, symptoms resulting after an auto accident can often take days to even weeks or months to manifest. Persistent neck pain that lasts for more than 3 months then becomes chronic neck pain, an issue which can be difficult to manage if not treated accordingly. Chronic neck pain may also result due to other underlying issues. The following article demonstrates which types of treatment methods can help relieve chronic neck pain symptoms and its associated complications, including capsular ligament laxity and cervical instability.

 

Chronic Neck Pain: Making the Connection Between Capsular Ligament Laxity and Cervical Instability

 

Abstract

 

The use of conventional modalities for chronic neck pain remains debatable, primarily because most treatments have had limited success. We conducted a review of the literature published up to December 2013 on the diagnostic and treatment modalities of disorders related to chronic neck pain and concluded that, despite providing temporary relief of symptoms, these treatments do not address the specific problems of healing and are not likely to offer long-term cures. The objectives of this narrative review are to provide an overview of chronic neck pain as it relates to cervical instability, to describe the anatomical features of the cervical spine and the impact of capsular ligament laxity, to discuss the disorders causing chronic neck pain and their current treatments, and lastly, to present prolotherapy as a viable treatment option that heals injured ligaments, restores stability to the spine, and resolves chronic neck pain.

 

The capsular ligaments are the main stabilizing structures of the facet joints in the cervical spine and have been implicated as a major source of chronic neck pain. Chronic neck pain often reflects a state of instability in the cervical spine and is a symptom common to a number of conditions described herein, including disc herniation, cervical spondylosis, whiplash injury and whiplash associated disorder, postconcussion syndrome, vertebrobasilar insufficiency, and Barr�-Li�ou syndrome.

 

When the capsular ligaments are injured, they become elongated and exhibit laxity, which causes excessive movement of the cervical vertebrae. In the upper cervical spine (C0-C2), this can cause a number of other symptoms including, but not limited to, nerve irritation and vertebrobasilar insufficiency with associated vertigo, tinnitus, dizziness, facial pain, arm pain, and migraine headaches. In the lower cervical spine (C3-C7), this can cause muscle spasms, crepitation, and/or paresthesia in addition to chronic neck pain. In either case, the presence of excessive motion between two adjacent cervical vertebrae and these associated symptoms is described as cervical instability.

 

Therefore, we propose that in many cases of chronic neck pain, the cause may be underlying joint instability due to capsular ligament laxity. Currently, curative treatment options for this type of cervical instability are inconclusive and inadequate. Based on clinical studies and experience with patients who have visited our chronic pain clinic with complaints of chronic neck pain, we contend that prolotherapy offers a potentially curative treatment option for chronic neck pain related to capsular ligament laxity and underlying cervical instability.

 

Keywords: Atlanto-axial joint, Barr�- Li�ou syndrome, C1-C2 facet joint, capsular ligament laxity, cervical instability, cervical radiculopathy, chronic neck pain, facet joints, post-concussion syndrome, prolotherapy, spondylosis, vertebrobasilar insufficiency, whiplash.

 

Introduction

 

In the realm of pain management, an ever-growing number of treatment-resistant patients are being left with relatively few conventional treatment options that effectively and permanently relieve their chronic pain symptoms. Chronic cervical spine pain is particularly challenging to treat, and data regarding the long-term efficacy of traditional therapies has been extremely discouraging [1]. The prevalence of neck pain in the general population has been reported to range between 30% and 50%, with women over 50 making up the larger portion [1-3]. Although many of these cases resolve with time and require minimal intervention, the recurrence rate of neck pain is high, and about one-third of people will suffer from chronic neck pain (defined as pain that persists longer than 6 months), and 5% will develop significant disability and reduction in quality of life [2, 4]. For this group of chronic pain patients, modern medicine offers few options for long-term recovery.

 

Treatment protocols for acute and sub-acute neck pain are standard and widely agreed upon [1, 2]. However, conventional treatments for chronic neck pain remain debatable and include interventions such as use of nonsteroidal anti-inflammatory drugs (NSAIDs) and narcotics for pain management, cervical collars, rest, physiotherapy, manual therapy, strengthening exercises, and nerve blocks. Furthermore, the literature on long-term treatment outcomes has been inconclusive at best [5-9]. Chronic neck pain due to whiplash injury or whiplash associated disorder (WAD) is particularly resistant to long-term treatment; conventional treatment for these conditions may give temporary relief but long-term outcomes have been disappointing [10].

 

In light of the poor treatment options and outcomes for chronic neck pain, we propose that in many of these cases, the underlying condition may be related to capsular ligament laxity and subsequent joint instability of the cervical spine. Should this be the case and joint instability is the fundamental problem causing chronic neck pain, a new treatment approach may be warranted.

 

The diagnosis of chronic neck pain due to cervical instability is particularly challenging. In most cases, diagnostic tools for detecting cervical instability have been inconsistent and lack specificity [11-15], and are therefore inadequate. A better understanding of the pathogenesis of cervical instability may better enable practitioners to recognize and treat the condition more effectively. For instance, when cervical instability is related to injury of soft tissue (eg, ligaments) alone and not fracture, the treatment modality should be one that stimulates the involved soft tissue to regenerate and repair itself.

 

Dr Jimenez works on wrestler's neck

 

In that context, comprehensive dextrose prolotherapy offers a promising treatment option for resolving cervical instability and the subsequent pain and disability it causes. The distinct anatomy of the cervical spine and the pathology of cervical instability described herein underlie the rationale for treating the condition with prolotherapy.

 

Anatomy

 

The cervical spine consists of the first seven vertebrae in the spinal column and is divided into two segments, the upper cervical (C0-C2) and lower cervical (C3-C7) regions. Despite having the smallest vertebral bodies, the cervical spine is the most mobile segment of the entire spine and must support a high degree of movement. Consequently, it is highly reliant on ligamentous tissue for stabilizing the neck and spinal column, as well as for controlling normal joint motion; as a result, the cervical spine is highly susceptible to injury.

 

The upper cervical spine consists of C0, called the occiput, and the first two cervical vertebrae, C1 and C2, or atlas and axis, respectively. C1 and C2 are more specialized than the rest of the cervical vertebrae. C1 is ring-shaped and lacks a vertebral body. C2 has a prominent vertebral body called the odontoid process or dens which acts as a pivot point for the C1 ring [16]. This pivoting motion (Fig. ?1), coupled with the lack of intervertebral discs in the upper cervical spine, allows for more movement and rotation of the joint, thus facilitating mobility rather than stability [17]. Collectively, the upper cervical spine is responsible for 50% of total neck flexion and extension at the atlanto-occipital (C0-C1) joint, as well as 50% of total neck rotation that occurs at the atlanto-axial joint (C1-C2) [16]. This motion is possible because the atlas (C1) rotates around the axis (C2) via the dens and the anterior arch of the atlas.

 

Figure 1 Atlanto-Axial Rotational Instability

Figure 1: Atlanto-axial rotational instability. The atlas is shown in the rotated position on the axis. The pivot is the eccentrically placed odontoid process. In rotation, the wall of the vertebral foramen of Cl decreases the opening of the spinal canal between Cl and C2. This can potentially cause migraine headaches, C2 nerve root impingement, dizziness, vertebrobasilar insufficiency, ‘drop attacks; neck-tongue syndrome, Barr�-Li�ou syndrome, severe neck pain, and tinnitus.

 

The intrinsic, passive stability of the spine is provided by the intervertebral discs and surrounding ligamentous structures. The upper cervical spine is stabilized solely by ligaments, including the transverse, alar, and capsular ligaments. The transverse ligament runs behind the dens, originating on a small tubercle on the medial side of a lateral mass of the atlas and inserting onto the identical tubercle on the other side. Thus, the transverse ligament restricts flexion of the head and anterior displacement of the atlas. The left and right alar ligaments originate from the posterior dens and attach to the medial occipital condyles on the ipsilateral sides. They work to limit axial rotation and are under the greatest tension in rotation and flexion. By holding C1 and C2 in proper position, the transverse and alar ligaments help to protect the spinal cord, brain stem, and nervous system from excess movement in the upper cervical spine [18].

 

The lower cervical spine, while less specialized, allows for the remaining 50% of neck flexion, extension, and rotation. Each vertebra in this region (C3-C7) has a vertebral body, in between which lies an intervertebral disc, the largest avascular structure of the body. This disc is a piece of fibrocartilage that helps cushion the joints and allows for more stability and is comprised of an inner gelatinous nucleus pulposus, which is surrounded by an outer, fibrous annulus fibrosus. The nucleus pulposus is designed to sustain compression loads and the annulus fibrosus, to resist tension, shear and torsion [19]. The annulus fibrosus is thought to determine the proper functioning of the entire intervertebral disc [20] and has been described as a lamellar structure consisting of 15-26 distinct concentric fibrocartilage layers that constitute a criss-crossing fiber matrix [19]. However, the form of this structure has been disputed. A microdissection study using cadavers reported that the cervical annulus fibrosus does not consist of concentric laminae of collagen fibers as it does in lumbar discs. Instead, the authors contend that the three-dimensional architecture of the cervical annulus fibrosus is more like that of a crescentic anterior interosseous ligament surrounding the nucleus pulposus [21].

 

In addition to the discs, multiple ligaments and the two synovial joints on each pair of adjacent vertebrae (facet joints) allow for controlled, fully three dimensional motions. Capsular ligaments wrap around each facet joint, which help to maintain stability during neck rotation. Each vertebra in the lower cervical spine (in addition to C2) contains a spinous process that serves as an attachment site for the interspinal ligaments. These tissues connect adjacent spinous processes and limit flexion of the cervical spine. Anteriorly, they meet with the ligamentum flavum.

 

Three other ligaments, the ligamentum flavum, anterior longitudinal ligament (ALL), and posterior longitudinal ligament (PLL), help to stabilize the cervical spine during motion and protect against excess flexion and extension of the cervical vertebrae. From C1-C2 to the sacrum, the ligamentum flava run down the posterior aspect of the spinal canal and join the laminae of adjacent vertebrae while helping to maintain proper neck posture. The ALL and PLL both run alongside the vertebral bodies. The ALL begins at the occiput and runs anteriorly to the anterior sacrum, helping to stabilize the vertebrae and intervertebral discs and limit spinal extension. The PLL also helps to stabilize the vertebrae and intervertebral discs, as well as limit spinal flexion. It extends from the body of the axis to the posterior sacrum and runs within the anterior aspect of the spinal canal across from the ligamentum flava.

 

A spinous process and two transverse processes emanate off the neural arch (or vertebral arch) which lies at the posterior aspect of the cervical vertebral column. The transverse processes are bony prominences that protrude postero-laterally and serve as attachment sites for various muscles and ligaments. With the exception of C7, each of these processes has a foramen which allows for passage of the vertebral artery towards the brain; the C7 transverse process has foramina which allow for passage of the vertebral vein and sympathetic nerves [22]. The transverse processes of the cervical vertebrae are connected via the intertransverse ligaments; each attaches a transverse process to the one below and helps to limit lateral flexion of the cervical spine.

 

Facet Joints

 

The inferior articular process of the superior cervical vertebra, except for C0-C1, and the superior articular process of the inferior cervical vertebra join to form the facet joints of the cervical spine; in the case of C0-C1, the inferior articular process of C1 joins the occipital condyles. Also referred to as zygapophyseal joints (Fig. ?2), the facet joints are diarrthrodial, meaning they function similar to the knee joint in that they contain synovial cells and joint fluid and are surrounded by a capsule. They also contain a meniscus which helps to further cushion the joint, and like the knee, are lined by articular cartilage and surrounded by capsular ligaments, which stabilize the joint. These capsular ligaments hold adjacent vertebrae to one another, and the articular cartilage therein is aligned such that its opposing tissue surfaces provide for a low-friction environment [23].

 

Figure 2 Typical Z Joint

Figure 2: Typical Z (zygapophyseal/ facet) joint. Each facet joint has articular cartilage, the synovium where synovial fluid is produced, and a meniscus.

 

There is some dissimilarity in facet joint anatomy between the upper and lower cervical spine. Even in the upper cervical region, C0-C1 and C1-C2 facet joints differ anatomically. At C0-C1, the convex shape of the occipital condyles enables them to fit into the concave surface of the inferior articular process. The C1-C2 facet joints are oriented cranio-caudally, meaning they run more parallel to their transverse processes. As such, their capsular ligaments are normally relatively lax, and thus, are inherently less stable and meant to facilitate mobility (i.e., rotation) [23, 24].

 

In contrast, the facet joints of the lower cervical spine are positioned at more of an angle. In the transverse plane, the angles of the right and left C2-C3 facet joints are estimated to be 32� to 65� and 32� to 60�, respectively, while those of the C6-C7 facet joints are typically steeper at 45� to 75� and 50� to 78� [25]. As the cervical spine extends downward, the angle of the facet joint becomes bigger such that the joint slopes backwards and downwards. Thus, the facet joints of the lower cervical spine have progressively less rotation than those of the upper cervical spine. Furthermore, the presence of intervertebral discs helps give the lower cervical spine more stability.

 

Nevertheless, injury to any of the facet joints can cause instability to the cervical spine. Researchers have found there is a continuum between the amount of trauma and degree of instability to the cervical facets, with greater trauma causing a higher degree of facet instability [26-28].

 

Cervical Capsular Ligaments

 

The capsular ligaments are extremely strong and serve as the main stabilizing tissue in the spinal column. They lie close to the intervertebral centers of rotation and provide significant stability in the neck, especially during axial rotation [29]; consequently, they serve as essential components for ensuring neck stability with movement. The capsular ligaments have a high peak force and elongation potential, meaning they can withstand large forces before rupturing. This was demonstrated in a dynamic mechanical study in which the capsular ligaments and ligamentum flavum were shown to have the highest average peak force, up to 220 N and 244 N, respectively [30]. This was reported as considerably greater than the force shown in the anterior longitudinal ligament and middle third disc.

 

While much has been reported about the strength of the capsular ligaments as related to cervical stability, when damaged, these ligaments lose their strength and are unable to support the cervical spine properly. For instance, in an animal study, it was shown that sequential removal of sheep capsular ligaments and cervical facets caused an undue increase in range of motion, especially in axial rotation, flexion and extension with caudal progression [31]. Human cadaver studies have also indicated that transection or injury of joint capsular ligaments significantly increases axial rotation and lateral flexion [32, 33]. Specifically, the largest increase in axial rotation with damage to a unilateral facet joint was 294% [33].

 

Capsular ligament laxity can occur instantaneously as a single macrotrauma, such as a whiplash injury, or can develop slowly as cumulative microtraumas, such as those from repetitive forward or bent head postures. In either case, the cause of injury occurs through similar mechanisms, leading to capsular ligament laxity and excess motion of the facet joints, which often results in cervical instability. When ligament laxity develops over time, it is defined as �creep� (Fig. ?3) and refers to the elongation of a ligament under a constant or repetitive stress [34]. While this constitutes low-level subfailure ligament injuries, it may represent the vast majority of cervical instability cases and can potentially incapacitate people due to disabling pain, vertigo, tinnitus or other concomitant symptoms of cervical instability. Such symptoms can be caused by elongation-induced strains of the capsular ligaments; these strains can progress to subsequent subfailure tears in the ligament fibers or to laxity in the capsular ligaments, leading to instability at the level of the cervical facet joints [35]. This is most evident when the neck is rotated (ie, looking to the left or right) and that movement�causes a �cracking� or �popping� sound. Clinical instability indicates that the spine is unable to maintain normal motion and function between vertebrae under normal physiological loads, inducing irritation to nerves, possible structural deformation, and/or incapacitating pain.

 

Figure 3 Ligament Laxity and Creep

Figure 3: Ligament laxity and creep. When ligaments are under a constant stress, they display creep behavior. Creep refers to a time-dependent increase in strain and causes ligaments to “stretch out” over time.

 

Furthermore, the capsular ligaments surrounding the facet joints are highly innervated by mechanoreceptive and nociceptive free nerve endings. Hence, the facet joint has long been considered the primary source of chronic spinal pain [36-38]. Additionally, injury to these nerves has been shown to affect the overall joint function of the facet joints [39]. Therefore, injury to the capsular ligaments and subsequent nerve endings could explain the prevalence of chronic pain and joint instability in the facet joints of the cervical spine.

 

Cervical Instability

 

Clinical instability is not to be confused with hypermobility. In general, instability implies a pathological condition with resultant symptoms, whereas joint hypermobility alone does not (Fig. ?4). Clinical instability refers to a loss of motion stiffness in a particular spinal segment when the application of force to it produces greater displacement(s) than would otherwise be seen in a normal structure. In clinical instability, symptoms such as pain and muscle spasms can thus be experienced within a person�s range of motion, not just at its furthest extension point. These muscle spasms can cause intense pain and are the body�s response to cervical instability in that the ligaments act as sensory organs involved in ligamento-muscular reflexes. The ligamento-muscular reflex is a protective reflex emanating from mechanoreceptors (ie, pacinian corpuscles, golgi tendon organs, and ruffini endings) in the ligaments and transmitted to the muscles. Subsequent activation of these muscles helps to preserve joint stability, either directly by muscles crossing the joint or indirectly by muscles that do not cross the joint but limit joint motion [40].

 

Figure 4 Cervical Spinal Motion Continuum and Role of Prolotherapy

Figure 4: Cervical spinal motion continuum and role of prolotherapy. When minor or moderate spinal instability occurs, treatment with prolotherapy may be of benefit in alleviating symptoms and restoring normal cervical joint function.

 

In a clinically unstable joint where neurologic insult is present, it is presumed that the joint has undergone more severe damage in its stabilizing structures, which may include the vertebrae themselves. In contrast, joints that are hypermobile demonstrate increased segmental mobility but are able to maintain their stability and function normally under physiological loads [41].

 

Clinical instability can be classified as mild, moderate or severe, with the later being associated with catastrophic injury. Minor injuries of the cervical spine are those involving soft tissues alone without evidence of fracture and are the most common causes of cervical instability. Mild or moderate clinical instability is that which is without neurologic (somatic) injury and is typically due to cumulative micro-traumas.

 

Diagnosis of Cervical Instability

 

Cervical instability is a diagnosis based primarily on a patient�s history (ie, symptoms) and physical examination because there is yet to be standardized functional X-rays or imaging able to diagnose cervical instability or detect ruptured ligamentous tissue without the presence of bony lesions [24]. For example, in one autopsy study of cryosection samples of the cervical spine, [42] only one out of ten gross ligamentous disruptions was evident on x-ray. Furthermore, there is often little correlation between the degree of instability or hypermobility shown on radiographic studies and clinical symptoms [43-45]. Even after severe whiplash injuries, plain radiographs are usually normal despite clinical findings indicating the presence of soft tissue damage.

 

However, functional computerized tomography (fCT) and magnetic resonance imaging (fMRI) scans and digital motion x-ray (DMX) are able to adequately depict cervical instability pathology [46, 47]. Studies using fCT for diagnosing soft tissue ligament or post-whiplash injuries have demonstrated the ability of this technique to show excess atlanto-occipital or atlanto-axial movement during axial rotation [48, 49]. This is especially pertinent when patients have signs and symptoms of cervical instability, yet have normal MRIs in a neutral position.

 

Functional imaging technology, as opposed to static standard films, is necessary for adequate radiologic depiction of instability in the cervical spine because they provide dynamic imaging of the neck during movement and are helpful for evaluating the presence and degree of cervical instability (Fig. ?5). There are also specialized physical examination tests specific for upper cervical instability, such as the Sharp-Purser test, upper cervical flexion test, and cervical flexion-rotation test.

 

Figure 5 3D CT Scan of Upper Cervical Spine

Figure 5: 3D CT scan of upper cervical spine. C1-C2 instability can easily be seen in the patient, as 70% of C1 articular facet is subluxed posteriorly (arrow) on C2 facet when the patient rotates his head (turns head to the left then the right).

 

Upper Cervical Pathology and Instability

 

Although not usually apparent radiographically, injury to the ligaments and soft tissues of C0-C2 from head or neck trauma is more likely than are cervical fractures or subluxation of bones [50, 51]. Ligament laxity across the C0-C1-C2 complex is primarily caused by rotational movements, especially those involving lateral bending and axial rotation [52-54]. With severe neck traumas, especially those with rotation, up to 25% of total lesions can be attributed to ligament injuries of C0-C2 alone. Although some ligament injuries in the C0-C2 region can cause severe neurological impairment, the majority involve sub-failure loads to the facet joints and capsular ligaments, which are the primary source of most chronic pain in post-neck trauma [26, 55].

 

Due to its lack of osseous stability, the upper cervical spine is also vulnerable to injury by high velocity manipulation. The capsular ligaments of the atlanto-axial joint are especially susceptible to injury from rotational thrusts, and thus, may be at risk during mechanically mediated manipulation. The capsular ligaments in the occipto-atlantal joint function as joint stabilizers and can also become injured due to excessive or abnormal forces [46].

 

Excessive tension on the capsular ligaments can cause upper cervical instability and related neck pain [56]. Capsular ligament tension is increased during abnormal postures, causing elongation of the capsular ligaments, with magnitudes increased by up to 70% of normal [57]. Such excessive ligament elongation induces laxity to the facet joints, which puts the cervical spine more at risk for further degenerative changes and instability. Therefore, capsular ligament injury appears to cause upper cervical instability because of laxity in the stabilizing structure of the facet joints [58].

 

Cervical Pain Versus Cervical Radiculopathy

 

According to the International Association for the Study of Pain (IASP), cervical spinal pain is pain perceived as anywhere in the posterior region of the cervical spine, defining it further as pain that is �perceived as arising from anywhere within the region bounded superiorly by the superior nuchal line, inferiorly by an imaginary transverse line through the tip of the first thoracic spinous process, and laterally by sagittal planes tangential to the lateral borders of the neck� [59]. Similarly, cervical pain is divided equally by an imaginary transverse plane into upper cervical pain and lower cervical pain. Suboccipital pain is that pain located between superior nuchal line and an imaginary transverse line through the tip of the second cervical spinous process. Likewise, cervico-occipital pain is perceived as arising in the cervical region and extending over the occipital region of the skull. These sources of pain could be a result of underlying cervical instability.

 

The IASP defines radicular pain as that arising in a limb or the trunk wall, caused either by ectopic activation of nociceptive afferent fibers in a spinal nerve or its roots or by other neuropathic mechanisms, and may be episodic, recurrent, or sudden [59]. Clinically, there is a 30% rate of radicular symptoms during axial rotation in those with rotator instabilities [60]. Thus, radicular pain may also be a result of underlying cervical instability.

 

With capsular ligament laxity, hypertrophic facet joint changes occur (including osteophytosis) as cervical degeneration progresses, causing encroachment on cervical nerve roots as they exit the spine through the neural foramina. This condition is called cervical radiculopathy and manifests as stabbing pain, numbness, and/or tingling down the upper extremity in the area of the affected nerve root.

 

The neural foramina lie between the intervertebral disc and the joints of Luschka (uncovertebral joints) anteriorly and the facet joint posteriorly. Their superior and inferior borders are the pedicles of adjacent vertebral bodies. Cervical nerve roots there are vulnerable to compression or injury by the facet joints posteriorly or by the joints of Luschka and the intervertebral disc anteriorly.

 

Cadaver studies have demonstrated that cervical nerve roots take up as much as 72% of the space in the neural foramina [61]. Normally, this provides ample room for the nerves to function optimally. However, if the cervical spine and capsular ligaments are injured, facet joint hypertrophy and degeneration of the cervical discs can occur. Over time, this causes narrowing of the neural foramina (Fig. ?6) and a decrease in space for the nerve root. In the event of another ligament injury, instability of the hypertrophied bones can occur and further reduce the patency of the neural foramen.

 

Figure 6 Digital Motion X-Ray Demonstrating Multi-Level Cervical Instability

Figure 6: Digital motion X-ray demonstrating multi-level cervical instability. Neural foraminal narrowing is shown at two levels during lateral extension versus lateral flexion.

 

Cervical radiculopathy from a capsular ligament injury typically produces intermittent radicular symptoms which become more noticeable when the neck is moved in a certain direction, such as during rotation, flexion or extension. These movements can cause encroachment on cervical nerve roots and subsequent paresthesia along the pathway therein of the affected nerve and may be why evidence of cervical radiculopathy does not show up on standard MRI or CT scans.

 

When disc herniation is the cause of cervical radiculopathy, it typically presents with acute onset of severe neck and arm pain unrelieved by any position and often results in encroachment on a cervical nerve root. While disc herniation can easily be seen on routine (non-functional) MRI or CT scans, evidence of radiculopathy from cervical instability cannot. Most cases of acute radiculopathy due to disc herniation resolve with non-surgical active or passive therapies, but some patients continue to have clinically significant symptoms, in which case surgical treatments such as anterior cervical decompression with fusion or posterior cervical laminoforaminotomy can be performed [62]. Cervical radiculopathy is also strongly associated with spondylosis, a disease generally attributed to aging that involves an overall degeneration of the cervical spine. The disorder is characterized by degenerative changes in the intervertebral disc, osteophytosis of the vertebral bodies, and hypertrophy of the facet joints and laminar arches. Since more than one cervical spine segment is usually affected in spondylosis, the symptoms of radiculopathy are more diffuse than those typical of unilateral soft disc herniation and present as neck, mid-upper back, and arm pain with paresthesia.

 

Dr Jimenez White Coat

Dr. Alex Jimenez’s Insight

“I was involved in an automobile accident that left me with chronic neck pain. What could be causing my painful and persistent neck pain symptoms?”�Being involved in an automobile accident can be a traumatic experience, resulting in both mental and physical harm. Whiplash-associated injuries are some of the most common diagnosis behind reported cases of chronic neck pain after an auto accident. During a car crash, the force of the impact can abruptly jerk the head back-and-forth, stretching the complex structures around the cervical spine beyond their natural range, causing damage or injury.The following article provides an overview of chronic neck pain, its mechanism of injury and effective treatment methods for neck pain.

 

Cervical Spondylosis: the Instability Connection

 

Spondylosis has previously been described as occurring in three stages: the dysfunctional stage, the unstable stage, and the stabilization stage (Fig. ?7) [63]. Spondylosis begins with repetitive trauma, such as rotational strains or compressive forces to the spine. This causes injury to the facet joints which can compromise the capsular ligaments. The dysfunctional phase is characterized by capsular ligament injuries and subsequent cartilage degeneration and synovitis, ultimately leading to abnormal motion in the cervical spine. Over time, facet joint dysfunction intensifies as capsular laxity occurs. This stretching response can cause cervical instability, marking the unstable stage. During this progression, ongoing degeneration is occurring in the intervertebral discs, along with other parts of the cervical spine. Ankylosis (stiffening of the joints) can also occur at the unstable cervical spine segment, and rarely, causes entrapment of nearby spinal nerves. The stabilization phase occurs with the formation of marginal osteophytes as the body tries to heal the spine. These bridging bony deposits can lead to a natural fusion of the affected vertebrae [64].

 

Figure 7 Cervical OA The 3 Phases of the Degenerative Cascade

Figure 7: Cervical OA: The 3 phases of the degenerative cascade. Used with permission from: Kramer WC, et al. Pathogenetic mechanisms of posttraumatic osteoarthritis: opportunities for early intervention. Int J Clin Exp Me d. 2011; 4(4): 285-298.

 

The degenerative cascade, however, begins long before symptoms become evident. Initially, spondylosis develops silently and is asymptomatic [65]. When symptoms of cervical spondylosis do develop, they are generally nonspecific and include neck pain and stiffness [66]. Only rarely do neurologic symptoms develop (ie, radiculopathy or myelopathy), and most often they occur in people with congenitally narrowed spinal canals [67]. Physical exam findings are often limited to restricted range of neck motion and poorly localized tenderness. Clinical symptoms commonly manifest when a new cervical ligament injury is superimposed on the underlying degeneration. In patients with spondylosis and underlying capsular ligament laxity, cervical radiculopathy is more likely to occur because the neural foramina may already be narrowed from facet joint hypertrophy and disc degeneration, enabling any new injury to more readily pinch on an exiting nerve root.

 

Thus, there are compelling reasons to believe that facet joint/capsular ligament injuries in the cervical spine may be an etiological basis for the degenerative cascade in cervical spondylosis and may be responsible for the attendant cervical instability. Animal models used for initiating disc degeneration in research studies have shown the induction of spinal instability through injury of the facet joints [68, 69]. In similar models, capsular ligament injuries of the facet joints caused multidirectional instability of the cervical spine, greatly increasing axial rotation motion correlating with cervical disc injuries [31, 28, 70, 71]. Using human specimens, surgical procedures such as discectomy have been shown to cause an immediate increase in motion of the segments involved [72]. Stabilization procedures such as neck fusion have been known to create increased pressure on the adjacent cervical spinal segments; this is referred to as adjacent segment disease. This can develop when the loss of motion from cervical fusion causes greater shearing and increased rotation and traction stress on adjacent vertebrae at the facet joints [73-75]. Thus, instability can �travel� up or down from the fused segment, furthering disc degeneration. These findings support the theory that iatrogenic-introduced stress and instability at adjacent spinal segments contribute to the pathogenesis of cervical spondylosis [74].

 

Whiplash Trauma

 

Damage to cervical ligaments from whiplash trauma has been well studied, yet these injuries are still often difficult to diagnose and treat. Standard x-rays often do not reveal present injury to the cervical spine and as a consequence, these injuries go unreported and patients are left without proper treatment for their condition [76]. Part of the difficulty lies in the fact that major injury to the cervical spine may only produce minor symptoms in some patients, whereas minor injury may produce more severe symptoms in others [77]. These symptoms include acute and/or chronic neck pain, headache, dizziness, vertigo and paresthesia in the upper extremities [78, 79].

 

MRI and autopsy studies have both shown an association between chronic symptoms in whiplash patients and injuries to the cervical discs, ligaments and facet joints [42, 80]. Success in relieving neck pain in whiplash patients has been documented by numerous clinical studies using nerve block and radiofrequency ablation of facet joint afferents, including capsular ligament nerves, such that increased interest has developed regarding the relationships between injury to the facet joints and capsular ligaments and post-whiplash dysfunction and related symptoms [36, 81].

 

Multiple studies have implicated the cervical facet joint and its capsule as a primary anatomical site of injury during whiplash exposure to the neck [55, 57, 82, 83]. Others have shown that injury to the cervical facet joints and capsular ligaments are the most common cause of pain in post-whiplash patients [84-86]. Cinephotographic and cineradiographic studies of both cadavers and human subjects show that under the conditions of whiplash, a resultant high impact force occurs in the cervical facet joints, leading to their injury and the possibility of cervical spine instability [84].

 

In whiplash trauma, up to 10 times more force is absorbed in the capsular ligaments versus the intervertebral disc [30]. Unlike the disc, the facet joint has a much smaller area in which to disperse this force. Ultimately, the capsular ligaments become elongated, resulting in abnormal motions in the spinal segments affected [30, 87]. This sequence has been documented with both in vitro and in vivo studies of segmental motion characteristics after torsional loads and resultant disc degeneration [88-90].

 

Injury to the facet joints and capsular ligaments has been further confirmed during simulated whiplash traumas [91]. Maximum capsular ligament strains occur during shear forces, such as when a force is applied while the head is rotated (axial rotation). While capsular ligament injury in the upper cervical spinal region can occur from compressive forces alone, exertion from a combination of shear, compression and bending forces is more likely and usually involves much lower loads to cause injury [92]. However, if the head is turned during whiplash trauma, the peak strain on the cervical facet joints and capsular ligaments can increase by 34% [93]. In one study reporting on an automobile rear-impact simulation, the magnitude of the joint capsule strain was 47% to 196% higher in instances when the head was rotated 60� during impact, compared with those when the head was forward facing [94]. The impact was greatest in the ipsilateral facet joints, such that head rotation to the left caused higher ligament strain at the left facet joint capsule.

 

In other simulations, whiplash trauma has been shown to reduce cervical ligament strength (ie, failure force and average energy absorption capacity) compared with controls or computational models [30, 87]; this is especially true in the case of capsular ligaments, since such trauma causes capsular ligament laxity. One study conclusively demonstrated that whiplash injury to the capsular ligaments resulted in an 85% to 275% increase in ligament elongation (ie, laxity) compared to that of controls [30]. The study also reported evidence that tension of the capsular ligaments is requisite for producing pain from the facet joint.

 

Post-Concussion Syndrome

 

Each year in the United States, approximately 1.7 million people are diagnosed with traumatic brain injury (TBI), although many more go undiagnosed because they do not seek out medical care [95]. Of these, approximately 75% – 90% are diagnosed as having a concussion. A concussion is considered a mild TBI and is defined as any transient neurologic dysfunction resulting from a biomechanical force, usually a sudden or forceful blow to the head which may or may not cause a loss of consciousness. Concussion induces a barrage of ionic, metabolic, and physiologic events [96] and manifests in a composite of symptoms affecting a patient�s physical, cognitive, and emotional states, and his or her sleep cycle, any one of which can be fleeting or long-term in duration [97]. The diagnosis of concussion is made by the presence of any one of the following: (1) any loss of consciousness; (2) any loss of memory for events immediately before or after the injury; (3) any alteration in mental status at the time of the accident; (4) focal neurological deficits that may or may not be transient [98].

 

While most individuals recover from a single concussion, up to one-third of those will continue to suffer from residual effects such as headache, neck pain, dizziness and memory problems one year after injury [99]. Such symptoms characterize a disorder known as post-concussion syndrome (PCS) and are much like those of WAD; both disorders are likely due to cervical instability. According to the International Classification of Diseases, 10th Revision (ICD-10), the diagnosis of PCS is made when a person has had a head injury sufficient enough to result in loss of consciousness and develops at least three of eight of the following symptoms within four weeks: headache, dizziness, fatigue, irritability, sleep problems, concentration difficulties, memory issues, and problems tolerating stress [100, 101]. Of those treated for PCS who had mild head injury, 80% report having chronic daily headaches; surprisingly, of those with moderate to severe head injury, only 27% reported having chronic daily headaches [102]. The impact of the brain on the skull is believed to be the cause of the symptoms of both concussion and PCS, although the specific mechanisms underlying neural tissue damage are still being investigated.

 

PCS-associated symptoms also overlap with many symptoms common to WAD. This overlap in symptomology may be due to a common etiology of underlying cervical instability that affects the cervical spine near the neck. Data has revealed that over half of patients with damage to the upper cervical spine from whiplash injury had evidence of concurrent head trauma [103]. It was shown that whiplash can cause minor brain injuries similar to that of concussion if it occurs with such rapid neck movement that there is a collision between the brain and skull. Thus, one may conjecture that concussion involves a whiplash-type injury to the neck.

 

Despite unique differences in the biomechanics of concussion and whiplash, both types of trauma involve an acceleration-deceleration of the head and neck. This impact to the head can not only cause injury to the brain and skull, but can also damage surrounding ligaments of the neck since these tissues undergo the same accelerating-decelerating force. The acceleration-deceleration forces which occur during whiplash injury are staggering. Direct head trauma has been shown to produce forces between 10,000 and 15,000 N on the head and between 1,000 and 1,500 N on the neck, depending on the angle at which the object hits the head [104, 105]. Cervical capsular ligaments can become lax with as little as 5 N of force, although most studies report cervical ligament failure at around 100 N [30, 55, 91, 106]. Even low speed rear impact collisions at as little as 7 mph to 8 mph can cause the head to move roughly 18 inches at a force as great as 7 G in less than a quarter of a second [107]. Numerous experimental studies have suggested that certain features of injury mechanisms including direction and degree of acceleration and deceleration, translation and rotation forces, position and posture of head and neck, and even seat construction may be linked to the extent of cervical spine damage and to the actual structures damaged [23, 27, 35, 50, 61].

 

Debate over the veracity of PCS or WAD symptomology has persisted; however, there is no single explanation for the etiology of these disorders, especially since the onset and duration of symptoms can vary greatly among individuals. Many of the symptoms of PCS and WAD tend to increase over time, especially when those affected are engaged in physical or cognitive activity. Chronic neck pain is often described as a long-term result of both concussion and whiplash, indicating that the most likely structures to become injured during these traumas are the capsular ligaments of the cervical facet joints. In light of this, we propose that the best scientific anatomical explanation is cervical instability in the upper cervical spine, resulting from ligament injury (laxity).

 

Vertebrobasilar Insufficiency

 

The occipito-atlanto-axial complex has a unique anatomical relationship with the vertebral arteries. In the lower cervical spine, the vertebral arteries lie in a relatively straight-forward course as they travel through the transverse foramina from C3-C6. However, in the upper cervical spine the arteries assume a more serpentine-like course. The vertebral artery emerges from the transverse process of C2 and sweeps laterally to pass through the transverse foramen of C1 (atlas). From there it passes around the posterior border of the lateral mass of C1, at which point it is farthest from the midline plane at the level of C1 [108, 109]. This pathway creates extra space which allows for normal head rotation without compromising vertebral artery blood flow.

 

Considering the position of the vertebral arteries in the canals of the transverse processes in the cervical vertebrae, it is possible to see how head positioning can alter vertebral arterial flow. Even normal physiological neck movements (ie, neck rotation) have been shown to cause partial occlusion of up to 20% or 30% in at least one vertebral artery [110]. Studies have shown that contralateral neck rotation is associated with vertebral artery blood flow changes, primarily between the atlas and axis; such changes can also occur when osteophytes are present in the cervical spine [111, 112].

 

Proper blood flow in the vertebral arteries is crucial because these arteries travel up to form the basilar artery at the brainstem and provide circulation to the posterior half of the brain. When this blood supply is insufficient, vertebrobasilar insufficiency (VBI) can develop and cause symptoms, such as neck pain, headaches/migraines, dizziness, drop attacks, vertigo, difficulty swallowing and/or speaking, and auditory and visual disturbances. VBI usually occurs in the presence of atherosclerosis or cervical spondylosis, but symptoms can also arise when there is intermittent vertebral artery occlusion induced by extreme rotation or extension of the head [113, 114]. This mechanical compression of the vertebral arteries can occur along with other anomalies, including cervical osteophytes, fibrous bands, and osseous prominences [115, 116] These anomalies were seen in about half of the cases of vertebral artery injury after cervical manipulation, as reported in a recent review [117].

 

Whiplash injury itself has been shown to reduce vertebral artery blood flow and elicit symptoms of VBI [118, 119]. In one study, the authors concluded that patients with persistent vertigo or dizziness after whiplash injury are likely to have VBI if the injury was traumatic enough to cause a circulation disorder in the vertebrobasilar arterial system [118]. Other researchers have surmised that excessive cervical instability, especially of the upper cervical spine, can cause obstruction of the vertebral artery during neck rotation, thus compromising blood flow and triggering symptoms [120-122].

 

Barr�-Li�ou Syndrome

 

A lesser known, yet relatively common, cause of neck pain is Barr�-Li�ou syndrome. In 1925, Jean Alexandre Barr�, and in 1928, Yong Choen Li�ou, each independently described a syndrome presenting with headache, orbital pressure/pain, vertigo, and vasomotor disturbances and proposed that these symptoms were related to alterations in the posterior cervical sympathetic chain and vertebral artery blood flow in patients who had cervical spine arthritis or other arthritic disorders [123, 124]. Barr�-Li�ou syndrome is also referred to as posterior cervical syndrome or posterior cervical sympathetic syndrome because the condition is now presumed to develop more from disruption of the posterior cervical sympathetic nervous system, which consists of the vertebral nerve and the sympathetic nerve network surrounding it. Symptoms include neck pain, headaches, dizziness, vertigo, visual and auditory disturbances, memory and cognitive impairment, and migraines. It has been surmised that cervical arthritis or injury provokes an irritation of both the vertebral and sympathetic nerves. As a result, current treatment now centers on resolution of cervical instability and its effects on the posterior sympathetic nerves [124]. Other research has found an association between the sympathetic symptoms of Barr�-Li�ou and cervical instability and has documented successful outcomes in case reports when the instability was addressed by various means including prolotherapy [125].

 

Symptoms of Barr�-Li�ou syndrome also appear to develop after trauma. In one study, 87% of patients with a diagnosis of Barr�-Li�ou syndrome reported that they began experiencing symptoms after suffering a cervical injury, primarily in the mid-cervical region [126]; in a related study, this same region was found to exhibit more instability than other spinal segments [127] The various symptoms that characterize Barr�-Li�ou syndrome can also mimic symptoms of PCS or WAD, [128] which can pose a challenge for practitioners in making a definitive diagnosis (Fig. ?8). The diagnosis of Barr�-Li�ou syndrome is made on clinical grounds, as there is yet to be a definitive test to document irritation of the sympathetic nervous system.

 

Figure 8 Overlap in Chronic Symptomology

Figure 8: Overlap in chronic symptomology between atlanto-axial instability, whiplash associated disorder, post-concussion syndrome, vertebrobasilar insufficiency, and Barr�-Li�ou syndrome. There is considerable overlap in symptoms amongst these conditions, possibly because they all appear to be due to cervical instability.

 

Other Sources of Cervical Pain

 

Various tensile forces place strains with differing deformations on a variety of viscoelastic spinal structures, including the ligaments, the annulus and nucleus of the intervertebral disc, and the spinal cord. Further to this, cadaver experiments have shown that the spinal cord and the intervertebral disc components carry considerably lower tensile forces than the spinal ligament column [129, 130]. Encapsulated mechanoreceptors and free nerve endings have been identified in the periarticular tissues of all major joints of the body including those in the spine, and in every articular tissue except cartilage [131]. Any innervated structure that has been injured by trauma is a potential chronic pain generator; this includes the intervertebral discs, facet joints, spinal muscles, tendons and ligaments [132-134].

 

The posterior ligamentous structures of the human spine are innervated by four types of nerve endings: pacinian corpuscles, golgi tendon organs, and ruffini and free nerve endings [40]. These receptors monitor joint excursion and capsular tension, and may initiate protective muscular reflexes that prevent joint degeneration and instability, especially when ligaments, such as the anterior and posterior longitudinal, ligamentum flavum, capsular, interspinous and supraspinous, are under too much tension [131, 135]. Collectively, the cervical region of the spinal column is at risk to sustain deformations at all levels and in all components, and when the threshold crosses a particular level at a particular component, injury is imminent owing to the relative increased flexibility or joint laxity.

 

Other Sources of Trauma

 

As described earlier, the nucleus pulposus is designed to sustain compression loads and the annulus fibrosus that surrounds it, to resist tension, shear and torsion. The stress in the annulus fibers is approximately 4-5 times the applied stress in the nucleus [136, 137]. In addition, annulus fibers elongate by up to 9% during torsional loading, but this is still well below the ultimate elongation at failure of over 25% [138]. Pressure within the nucleus is approximately 1.5 times the externally applied load per unit of disc area. As such, the nucleus is relatively incompressible, which causes the intervertebral disc to be susceptible to injury in that it bulges under loads – approximately 1 mm per physiological load [139]. As the disc degenerates on bulging (herniates), it looses elasticity, further compromising its ability to compress. Shock absorption is no longer spread or absorbed evenly by the surrounding annulus, leading to greater shearing, rotation, and traction stress on the disc and adjacent vertebrae. The severity of disc herniation can range from protrusion and bulging of the disc without rupture of the annulus fibrosus to disc extrusion, in which case, the annulus is perforated, leading to tearing of the structure.

 

Dr Jimenez White Coat

Dr. Alex Jimenez’s Insight

“What type of treatment methods can provide effective relief from my chronic neck pain symptoms?”�The symptoms of chronic neck pain can be debilitating and can ultimately affect any individual’s ability to carry on with their everyday activities. While neck pain is a common symptom in a variety of injuries and/or conditions affecting the cervical spine, there are also a number of treatment methods available to help improve neck pain. However, some treatments also address stabilizing the cervical spine as well as healing damaged or injured tissues. Chiropractic care is a well-known alternative treatment option which has been demonstrated to help cure symptoms of neck pain at the source, according to several research studies.

 

Treatment Options

 

There are a number of treatment modalities for the management of chronic neck pain and cervical instability, including injection therapy, nerve blocks, mobilization, manipulation, alternative medicine, behavioral therapy, fusion, and pharmacologic agents such as NSAIDS and opiates. However, these treatments do not address stabilizing the cervical spine or healing ligament injuries, and thus, do not offer long-term curative options. In fact, cortisone injections are known to inhibit, rather than promote healing. As mentioned earlier in this paper, most treatments have shown limited evidence in their efficacy or are inconsistent in their results. In a systematic review of the literature from January 2000 to July 2012 on physical modalities for acute to chronic neck pain, acupuncture, laser therapy, and intermittent traction were found to provide moderate benefits [5].

 

The literature contains many reports on injection therapy for the treatment of chronic neck pain. Cervical interlaminar epidural injections with or without steroids may provide significant improvement in pain and function for patients with cervical disc herniation and radiculitis [140]. As a follow-up to its one-year results, a randomized, double-blind controlled trial found that the clinical effectiveness of therapeutic cervical medial branch blocks with or without steroids in managing chronic neck pain of facet joint origin provided significant improvement over a period of 2 years [141].

 

However, many other studies have had more nebulous results. In a systematic review of therapeutic cervical facet joint interventions, the evidence for both cervical radiofrequency neurotomy and cervical medial branch blocks is fair, and for cervical intra-articular injections with local anesthetic and steroids, the evidence is limited [142]. In a later corresponding systematic review, the same group of authors concluded that the strength of evidence for diagnostic facet joint nerve blocks is good (?75% pain relief), but stated the evidence is limited for dual blocks (50% to 74% pain relief), as well as for single blocks (50% to 74% pain relief) and (?75% pain relief.) [6]. In another systematic review evaluating cervical interlaminar epidural injections, the evidence indicated that the injection therapy showed significant effects in relieving chronic intractable pain of cervical origin; specific to long-term relief the indicated level of evidence was Level II-1 [143].

 

In the case of manipulative therapy, the results of a randomized trial disputed the hypothesis that supervised home exercises, combined or not with manual therapy, can be of benefit in treating non-specific chronic neck pain, as compared to no treatment [7]. The study found that there were no differences in primary or secondary outcomes among the three groups and that no significant change in health-related quality of life was associated with the preventive phase. Participants in the combined intervention group did not have less pain or disability and fared no better functionally than participants from the two other groups during the preventive phase of the trial. Another randomized clinical trial comparing the effects of applying joint mobilization at symptomatic and asymptomatic cervical levels in patients with chronic nonspecific neck pain was inconclusive in that there was no significant difference in pain intensity immediately after treatment between groups during resting position, painful active movement, or vertebral palpation [8]. Massage therapy had similar inconclusive results. Evidence was reported as �not strong� [144] in one randomized trial comparing groups receiving massage treatment for neck pain versus those reading a self-care book, while another found that cupping massage was no more effective than progressive muscle relaxation in reducing chronic non-specific neck pain [9]. Acupuncture appears to have better results in relieving neck pain but leaves questions as to the effects on the autonomic nervous system, suggesting that acupuncture points per se have different physical effects according to location [145].

 

Cervical disc herniation is a major source of chronic neck and spinal pain and is generally treated by either surgery or epidural injections, but their effectiveness continues to be debatable. In a randomized, double-blind, controlled clinical trial assigning patients to treatment with epidural injections with lidocaine or lidocaine mixed with betamethasone, 72% of patients in the local anesthetic group and 68% of patients in the local anesthetic with steroid group had at least a 50% improvement in pain and disability at 2 years, indicating that either protocol may be beneficial in alleviating chronic pain from cervical disc herniation [146].

 

In a systematic review of pharmacological interventions for neck pain, Peloso, et al. [147] reported that, aside from evidence in one study of a small immediate benefit for the psychotropic agent eperison hydrochloride (a muscle relaxant), most studies had low to very low quality methodologic evidence. Furthermore, they found evidence against a long-term benefit for medial branch block of facet joints with steroids and against a short-term benefit for botulinum toxin-A compared to saline, concluding that there is a lack of evidence for most pharmacological interventions.

 

Collectively, these interventions for the treatment of chronic neck pain may each offer temporary relief, but many fall short of a cure. Aside from these conventional treatment options, there are pain medications and pain patches, but their use is controversial because they offer little restorative value and often lead to dependence. If joint instability is the fundamental problem causing chronic neck pain and its associated autonomic symptoms, prolotherapy may be a treatment approach that meets this challenge.

 

Prolotherapy for Cervical Instability

 

To date, there is no consensus on the diagnosis of cervical spine instability or on traditional treatments that relieve chronic neck pain. In such cases, patients often seek out alternative treatments for pain and symptom relief. Prolotherapy is one such treatment which is intended for acute and chronic musculoskeletal injuries, including those causing chronic neck pain related to underlying joint instability and ligament laxity (Fig. ?9).

 

Figure 9 Stress-Strain Curve for Ligaments and Tendons

Figure 9: Stress-strain curve for ligaments and tendons. Ligaments can withstand forces and revert back to their original position up to Point C. At this point, prolotherapy treatment may succeed in tightening the tissue. Once the force continues past Point C. the ligament becomes permanently elongated or stressed.

 

Chronic neck pain and cervical instability are particularly difficult to treat when capsular ligament laxity is the cause because ligament cartilage is notoriously slow in healing due to a lack of blood supply. Most treatment options do not address this specific problem, and therefore, have limited success in providing a long-term cure.

 

Whiplash is a prime example because it often results in ligament laxity. In a five-part series evaluating the strength of evidence supporting WAD therapies, Teasell, et al. [10, 148-151] report that there is insufficient evidence to support any treatment for subacute WAD, stating that radiofrequency neurotomy may be the most effective treatment for chronic WAD. Furthermore, they state that immobilization with a soft collar is ineffective to the point of impeding recovery, saying that activation-based therapy is recommended instead, a conclusion similar to that of Hauser et al. [40] For chronic WAD, exercise programs were the most effective noninvasive treatment and radiofrequency neurotomy, the most effective of surgical or injection-based interventions, although evidence was not strong enough to establish the efficacy of any one treatment [10].

 

Prolotherapy is referred to as a regenerative injection technique (RIT) because it is based on the premise that the regenerative/reparative healing process consists of three overlapping phases: inflammatory, proliferative with granulation, and remodeling with contraction (Fig. ?10) [152]. The prolotherapy technique involves injecting an irritating solution (usually a dextrose/sugar solution) at painful ligament and tendon attachment sites to produce a mild inflammatory response. Such a response initiates a healing cascade that duplicates the natural healing process of poorly vascularized tissue (ligaments, tendons, and cartilage) [40, 153]. In doing so, tensile strength, elasticity, mass and load-bearing capacity of collagenous connective tissues become increased [152]. This occurs because the increased glucose concentration causes increases in cell protein synthesis, DNA synthesis, cell volume, and proliferation, all of which stimulate ligament size and mass and ligament-bone junction strength, as well as the production of growth factors, which are essential for ligament repair and growth [154].

 

Figure 10 The Biology of Prolotherapy

Figure 10: The biology of prolotherapy.

 

While the most studied type of prolotherapy is the Hackett-Hemwall procedure which uses dextrose as the proliferant, there are multiple other choices that are suitable, such as polidocanol, manganese, human growth hormone, and zinc. In addition to the Hackett-Hemwall procedure, there is another procedure called cellular prolotherapy, which involves the use of a patient�s own cells from blood, bone marrow, or adipose tissue as the proliferant to generate healing.

 

It is important to note that prolotherapy not only involves the treatment of joints, but also the associated tendon and ligament attachments surrounding them; hence, it is a comprehensive and highly effective means of wound healing and pain resolution. The Hackett-Hemwall prolotherapy technique was developed in the 1950s and is being transitioned into mainstream medicine due to an increasing number of studies reporting positive outcomes [155-158].

 

Prolotherapy has a long history of being used for whiplash-type soft tissue injuries of the neck. In separate studies, Hackett and his colleagues early on had remarkably successful outcomes in treating ligament injuries; more than 85% of patients with cervical ligament injury-related symptoms, including those with headache or WAD, reported they had minor to no residual pain or related symptoms after prolotherapy [125, 159, 160]. Similar favorable outcomes for resolving neck pain were reported recently by Hauser, et al. [161]. Hooper, et al. also reported on a case series [162] in which patients with whiplash received intra-articular injections (prolotherapy) into each zygapophysial (facet)

 

joint and attained consistently improved scores in the Neck Disability Index (NDI) at 2, 6 and 12 months post treatment; average change in Neck Disability Index (NDI) was significant (13.77; p < 0.001) at baseline versus 12 months. Specific to cervical instability, Centeno, et al. [163] performed fluoro-scopically guided prolotherapy and reported that stabilization of the cervical spine with prolotherapy correlated with symptom relief, as depicted in blinded pre and post radiographic readings. Prolotherapy has also been found effective for other ligament injuries, including the lower back, [164-166] knee, [167-169] and other peripheral joints, [170-172] as well as congenital systemic ligament laxity conditions [173].

 

Evidence that prolotherapy induces the repair of ligaments and other soft tissue structures has been reported in both animal and human studies. Animal research conducted by Hackett [174] demonstrated that proliferation and strengthening of tendons occurred, while Liu and associates [175] found that prolotherapy injections to rabbit ligaments increased ligamentous mass (44%), thickness (27%), as well as ligament-bone junction strength (28%) over a six-week period. In a study on human subjects, Klein et al. [176] used electron microscopy and found an average increase in ligament diameter from 0.055 �m to 0.087 �m after prolotherapy, as shown in biopsies of posterior sacroi-liac ligaments. They also found a linear ligament orientation similar to what is found in normal ligaments. In a case study, Auburn, et al. [177] documented a 27% increase in iliolum-bar ligament size after prolotherapy, via ultrasound.

 

Studies have also been published on the use of prolotherapy for resolving chronic pain, [152, 178, 179] as well as for conditions specifically related to joint instability in the cervical spine [163, 180] In our own pain clinic, we have used prolotherapy successfully on patients who had chronic pain in the shoulder, elbow, low back, hip, and knee [181-186].

 

Conclusion

 

The capsular ligaments are the main stabilizing structures of the facet joints in the cervical spine and have been implicated as a major source of chronic neck pain. Such pain often reflects a state of instability in the cervical spine and is a symptom common to a number of conditions such as disc herniation, cervical spondylosis, whiplash injury and whiplash associated disorder, postconcussion syndrome, vertebrobasilar insufficiency, and Barr�-Li�ou syndrome.

 

When the capsular ligaments are injured, they become elongated and exhibit laxity, which causes excessive movement of the cervical vertebrae. In the upper cervical spine (C0-C2), this can cause symptoms such as nerve irritation and vertebrobasilar insufficiency with associated vertigo, tinnitus, dizziness, facial pain, arm pain, and migraine headaches. In the lower cervical spine (C3-C7), this can cause muscle spasms, crepitation, and/or paresthesia in addition to chronic neck pain. In either case, the presence of excessive motion between two adjacent cervical vertebrae and these associated symptoms is described as cervical instability.

 

Therefore, we propose that in many cases of chronic neck pain, the cause may be underlying joint instability due to capsular ligament laxity. Furthermore, we contend that the use of comprehensive Hackett-Hemwall prolotherapy appears to be an effective treatment for chronic neck pain and cervical instability, especially when due to ligament laxity. The technique is safe and relatively non-invasive as well as efficacious in relieving chronic neck pain and its associated symptoms. Additional randomized clinical trials and more research into its use will be needed to verify its potential to reverse ligament laxity and correct the attendant cervical instability.

 

Dr. Jimenez works on patient's back

 

Acknowledgements

 

Declared none.

 

Conflict of Interest

 

Ms. Woldin and Ms. Sawyer have nothing to declare. Dr. Hauser and Ms. Steilen declare that they perform prolotherapy at Caring Medical Rehabilitation Services.

 

Dr Jimenez White Coat

Dr. Alex Jimenez’s Insight

“I was diagnosed with a whiplash-associated disorder after reporting chronic neck pain symptoms following an automobile accident. What form of care can help me manage the persistent symptoms?”�In order to manage chronic neck pain symptoms, not only is it essential for you to seek immediate medical attention from the proper healthcare professional, its also important to understand the mechanism of injury behind your persistent symptoms. Tendons, ligaments and other structures surrounding the cervical spine, such as the facet joints, can become damaged or injured during an auto accident and their care must be consistent to achieve overall recovery. Many healthcare professionals can provide patients with individualized guidelines on the management of their whiplash-associated disorders and chronic neck pain.

 

Facet Joint Kinematics and Injury Mechanisms During Simulated Whiplash

 

Abstract

 

Study Design: Facet joint kinematics and capsular ligament strains were evaluated during simulated whiplash of whole cervical spine specimens with muscle force replication.

 

Objectives: To describe facet joint kinematics, including facet joint compression and facet joint sliding, and quantify peak capsular ligament strain during simulated whiplash.

 

Summary of Background Data: Clinical studies have implicated the facet joint as a source of chronic neck pain in whiplash patients. Prior in vivo and in vitro biomechanical studies have evaluated facet joint compression and excessive capsular ligament strain as potential injury mechanisms. No study has comprehensively evaluated facet joint compression, facet joint sliding, and capsular ligament strain at all cervical levels during multiple whiplash simulation accelerations.

 

Methods: The whole cervical spine specimens with muscle force replication model and a bench-top trauma sled were used in an incremental trauma protocol to simulate whiplash of increasing severity. Peak facet joint compression (displacement of the upper facet surface towards the lower facet surface), facet joint sliding (displacement of the upper facet surface along the lower facet surface), and capsular ligament strains were calculated and compared to the physiologic limits determined during intact flexibility testing.

 

Results: Peak facet joint compression was greatest at C4-C5, reaching a maximum of 2.6 mm during the 5 g simulation. Increases over physiologic limits (P < 0.05) were initially observed during the 3.5 g simulation. In general, peak facet joint sliding and capsular ligament strains were largest in the lower cervical spine and increased with impact acceleration. Capsular ligament strain reached a maximum of 39.9% at C6-C7 during the 8 g simulation.

 

Conclusions: Facet joint components may be at risk for injury due to facet joint compression during rear-impact accelerations of 3.5 g and above. Capsular ligaments are at risk for injury at higher accelerations.

 

The Treatment of Neck Pain-Associated Disorders and Whiplash-Associated Disorders: A Clinical Practice Guideline

 

Abstract

 

Objective: The objective was to develop a clinical practice guideline on the management of neck pain-associated disorders (NADs) and whiplash-associated disorders (WADs). This guideline replaces 2 prior chiropractic guidelines on NADs and WADs.

 

Methods: Pertinent systematic reviews on 6 topic areas (education, multimodal care, exercise, work disability, manual therapy, passive modalities) were assessed using A Measurement Tool to Assess Systematic Reviews (AMSTAR) and data extracted from admissible randomized controlled trials. We incorporated risk of bias scores in the Grading of Recommendations Assessment, Development, and Evaluation. Evidence profiles were used to summarize judgments of the evidence quality, detail relative and absolute effects, and link recommendations to the supporting evidence. The guideline panel considered the balance of desirable and undesirable consequences. Consensus was achieved using a modified Delphi. The guideline was peer reviewed by a 10-member multidisciplinary (medical and chiropractic) external committee.

 

Results: For recent-onset (0-3 months) neck pain, we suggest offering multimodal care; manipulation or mobilization; range-of-motion home exercise, or multimodal manual therapy (for grades I-II NAD); supervised graded strengthening exercise (grade III NAD); and multimodal care (grade III WAD). For persistent (>3 months) neck pain, we suggest offering multimodal care or stress self-management; manipulation with soft tissue therapy; high-dose massage; supervised group exercise; supervised yoga; supervised strengthening exercises or home exercises (grades I-II NAD); multimodal care or practitioner’s advice (grades I-III NAD); and supervised exercise with advice or advice alone (grades I-II WAD). For workers with persistent neck and shoulder pain, evidence supports mixed supervised and unsupervised high-intensity strength training or advice alone (grades I-III NAD).

 

Conclusions:�A multimodal approach including manual therapy, self-management advice, and exercise is an effective treatment strategy for both recent-onset and persistent neck pain.

 

Copyright � 2016. Published by Elsevier Inc.

 

Keywords: Chiropractic; Disease Management; Musculoskeletal Disorders; Neck Pain; Practice Guideline; Therapeutic Intervention; Whiplash Injuries

 

In conclusion, chronic neck pain, particularly that resulting from whiplash-associated disorders, can be treated using treatment methods which focus on the rehabilitation of the complex structures surrounding the cervical spine. Furthermore, by understanding chronic neck pain as it relates to cervical instability as well as its impact on capsular ligament laxity, patients can seek the proper treatment for their type of chronic neck pain, including whiplash. Information referenced from the National Center for Biotechnology Information (NCBI). The scope of our information is limited to chiropractic as well as to spinal injuries and conditions. To discuss the subject matter, please feel free to ask Dr. Jimenez or contact us at 915-850-0900 .

 

Curated by Dr. Alex Jimenez

 

Green-Call-Now-Button-24H-150x150-2-3.png

 

Additional Topics: Neck Pain

 

Neck pain is a common complaint which can result due to a variety of injuries and/or conditions. According to statistics, automobile accident injuries and whiplash injuries are some of the most prevalent causes for neck pain among the general population. During an auto accident, the sudden impact from the incident can cause the head and neck to jolt abruptly back-and-forth in any direction, damaging the complex structures surrounding the cervical spine. Trauma to the tendons and ligaments, as well as that of other tissues in the neck, can cause neck pain and radiating symptoms throughout the human body.

 

blog picture of cartoon paperboy big news

 

IMPORTANT TOPIC: EXTRA EXTRA: A Healthier You!

 

 

Blank
References
1. Childs J, Cleland J, Elliott J , et al. Neck pain clinical practice guidelines linked to the international classification of functioning, disability, and health from the orthopaedic section of the American Physical Therapy Association. J Orthop Sports Phys Ther. 2008;38(9): A1�34. [PubMed]
2. C�t� P, Cassidy JD, Carroll LJ, Kristman V. The annual incidence and course of neck pain in the general population a population based cohort study. Pain. 2004;112(3): 267�73. [PubMed]
3. Hogg-Johnson S, van der Velde G, Carroll LJ , et al. The burden and determinants of neck pain in the general population. Eur Spine J. 2008;17(Suppl 1 ): 39�51.
4. Childs JD, Fritz JM, Flynn TW , et al. A clinical prediction rule to identify patients with low back pain most likely to benefit from spinal manipulation a validation study. Ann Intern Med. 2004;141(12): 920�8. [PubMed]
5. Graham N, Gross AR, Carlesso LC , et al. ICON. An ICON overview on physical modalities for neck pain and associated disorders. Open Orthop J. 2013;7(Suppl 4 ): 440�60. [PMC free article] [PubMed]
6. Onyewu O, Manchikanti L, Falco FJE , et al. An update of the appraisal of the accuracy and utility of cervical discography in chronic neck pain. Pain Physician. 2012;15: E777�806. [PubMed]
7. Martel J, Dugas C, Dubois JD, Descarreaux M. A randomised controlled trial of preventive spinal manipulation with and without a home exercise program for patients with chronic neck pain. BMC Musculoskelet Disord. 2011;12: 41. [PMC free article] [PubMed]
8. Aquino RL, Caires PM, Furtado FC, Loureiro AV, Ferreira PH, Ferreira ML. Applying joint mobilization at different cervical vertebral levels does not influence immediate pain reduction in patients with chronic neck pain a randomized clinical trial. J Manual Manipulative Ther. 2009;17(2): 95�100. [PMC free article] [PubMed]
9. Lauche R, Materdey S, Cramer H , et al. Effectiveness of home-based cupping massage compared to progressive muscle relaxation in patients with chronic neck pain-a randomized controlled trial. PLoS ONE. 2013;8(6): e65378. [PMC free article] [PubMed]
10. Teasell RW, McClure JA, Walton D , et al. A research synthesis of therapeutic interventions for whiplash-associated disorder (WAD): part 1 – overview and summary. Pain Res Manage. 2010;15(5): 287�94. [PMC free article] [PubMed]
11. Murphy DR, Hurwitz EL. Application of a diagnosis-based clinical decision guide in patients with neck pain. Chiropr Manual Ther. 2011;19: 19. [PMC free article] [PubMed]
12. Suzuki F, Fukami T, Tsuji A, Takagi K, Matsuda M. Discrepancies of MRI findings between recumbent and upright positions in atlantoaxial lesion. Report of two cases. Eur Spine J. 2008;17(Suppl 2 ): S304�7. [PMC free article] [PubMed]
13. R�ijezon U, Djupsj�backa M, Bj�rklund M, H�ger-Ross C, Grip H, Liebermann DG. Kinematics of fast cervical rotations in persons with chronic neck pain a cross-sectional and reliability study. BMC Musculoskelet Disord. 2010;11: 22. [PMC free article] [PubMed]
14. Gelalis ID, Christoforou G, Arnaoutoglou CM, Politis AN, Manoudis G, Xenakis TA. Misdiagnosed bilateral C5-C6 dislocation causing cervical spine instability a case report. Cases J. 2009;2: 6149. [PMC free article] [PubMed]
15. Taylor M, Hipp JA, Gertzbein SD, Gopinath S, Reitman CA. Observer agreement in assessing flexion-extension X-rays of the cervical spine, with and without the use of quantitative measurements of intervertebral motion. Spine J. 2007;7(6): 654�8. [PMC free article] [PubMed]
16. Windsor RE. Cervical spine anatomy. http: //emedicine.medscape. com/article/1948797-overview#a30 [Accessed April 14. 2014.
17. Driscoll DR. Anatomical and biomechanical characteristics of upper cervical ligamentous structures a review. J Manipulative and Physiol Ther. 1987;10(3): 107�10. [PubMed]
18. Cusick JF, Yoganandan N. Biomechanics of the cervical spine part 4: major injuries. Clin Biomech. 2002;17(1): 1�20. [PubMed]
19. Nachemson A. The influence of spinal movements of the lumbar intradiscal pressure on the tensile stresses in the annulus fibrosus. Acta Orthop Scan. 1963;33: 183�207. [PubMed]
20. Zak M, Pezowicz C. Spinal sections and regional variations in the mechanical properties of the annulus fibrosus subjected to tensile loading. Acta Bioeng Biomech. 2013;15(1): 51�9. [PubMed]
21. Mercer S, Bogduk N. The ligaments and annulus fibrosus of human adult cervical intervertebral discs. Spine (Phila Pa 1976). 1999;24(7): 619�28. [PubMed]
22. Kuri J, Stapleton E. The spine at trial practical medicolegal concepts about the spine. http: //books.google.com/books?id=Gi6w jdftC7cC&pg=PA12&lpg=PA12&dq=cervical+spine+transverse+processes&source=bl&ots=tboGEQAnuB&sig=Vi4bIDA24bLxGWWEivgAmmlETFo&hl=en&sa=X&ei=YETZUteXHMTAyAGNkICIBQ&ved=0CDYQ6AEwAjgK#v=onepage&q=cervical%20spine%20transverse%20processes&f=false [Accessed April 14. 2014.
23. Jaumard N, Welch WC, Winkelstein BA. Spinal facet joint biomechanics and mechanotransduction in normal, injury, and degenerative conditions. J Biomech Eng. 2011;133(7): 071010. [PMC free article] [PubMed]
24. Volle E. Functional magnetic resonance imaging video diagnosis of soft-tissue trauma to the craniocervical joints and ligaments. Int Tinnitus J. 2000;6(2): 134�9. [PubMed]
25. Pal GP, Routal RV, Saggu KG. The orientation of the articular facets of the zygapophyseal joints at the cervical and upper thoracic region. J Anat. 2001;198(Pt 4): 431�41. [PMC free article] [PubMed]
26. Quinn KP, Lee KE, Ahaghotu CC, Winkelstein BA. Structural changes in the cervical facet capsular ligament potential contributions to pain following subfailure loading. Stapp Car Crash J. 2007;51: 169�87. [PubMed]
27. Panjabi MM, Bibu K, Cholewicki J. Whiplash injuries and the potential for mechanical instability. Eur Spine J. 1998;7: 484�92. [PMC free article] [PubMed]
28. Zdeblick TA, Abitbol JJ, Kunz DN, McCabe RP, Garfin S. Cervical stability after sequential capsule resection. Spine (Phila Pa 1976). 1993;18: 2005�8. [PubMed]
29. Rasoulinejad P, McLachlin SD, Bailey SI, Gurr KR, Bailey CS, Dunning CE. The importance of the posterior osteoligamentous complex to subaxial cervical spine stability in relation to a unilateral facet injury. Spine J. 2012;12(7): 590�5. [PubMed]
30. Ivancic PC, Coe MP, Ndu AB , et al. Dynamic mechanical properties of intact human cervical spine ligaments. Spine J. 2007;7(6): 659�65. [PMC free article] [PubMed]
31. DeVries NA, Gandhi AA, Fredericks DC, Grosland NM, Smucker JD. Biomechanical analysis of the intact and destabilized sheep cervical spine. Spine (Phila Pa 1976). 2012;37(16): E957�63. [PubMed]
32. Crisco JJ, 3rd, Oda T, Panjabi MM, Bueff HU, Dvor�k J, Grob D. Transections of the C1-C2 joint capsular ligaments in the cadaveric spine. Spine (Phila Pa 1976). 1991;16: S474�9. [PubMed]
33. Nadeau M, McLachlin SD, Bailey SI, Gurr KR, Dunning CE, Bailey CS. A biomechanical assessment of soft-tissue damage in the cervical spine following a unilateral facet injury. J Bone Joint Surg. 2012;94(21): e156. [PubMed]
34. Frank CB. Ligament structure, physiology, and function. J Musculoskelet Neuronal Interact. 2004;4(2): 199�201. [PubMed]
35. Chen HB, Yang KH, Wang ZG. Biomechanics of whiplash injury. Chin J Traumatol. 2009;12(5): 305�14. [PubMed]
36. Boswell MV, Colson JD, Sehgal N, Dunbar EE, Epter R. A systematic review of therapeutic facet joint interventions in chronic spinal pain. Pain Physician. 2007;10(1): 229�53. [PubMed]
37. Aprill C, Bogduk N. The prevalence of cervical zygapophyseal joint pain a first approximation. Spine (Phila Pa 1976). 1992;17: 744�7. [PubMed]
38. Barnsley L, Lord SM, Wallis BJ, Bogduk N. The prevalence of cervical zygapophaseal joint pain after whiplash. Spine (Phila Pa 1976). 1995;20: 20�5. [PubMed]
39. McLain RF. Mechanoreceptor endings in human cervical facet joints. Iowa Orthop J. 1993;13: 149�54. [PMC free article] [PubMed]
40. Hauser RA, Dolan EE, Phillips HJ, Newlin AC, Moore RE Woldin BA. Ligament injury and healing a review of current clinical diagnostics and therapeutics. Open Rehabil J. 2013;6: 1�20.
41. Bergmann TF, Peterson DH. Chiropractic technique principles and procedures, 3rd ed. New York Mobby Inc. 1993
42. J�nsson H , Jr, Bring G, Rauschning W, Sahlstedt B. Hidden cervical spine injuries in traffic accident victims with skull fractures. J Spinal Disord. 1991;4(3): 251�63. [PubMed]
43. van Mameren H, Drukker J, Sanches H, Beursgens J. Cervical spine motion in the sagittal plane (I) range of motion of actually performed movements, an x-ray cinematographic study. Eur J Morphol. 1990;28(1): 47�68. [PubMed]
44. van Mameren H, Sanches H, Beursgens J, Drukker J. Cervical spine motion in the sagittal plane II positions of segmental averaged instantaneous centers of rotation-a cineradiographic study. Spine (Phila Pa 1976). 1992;17(5): 467�74. [PubMed]
45. Bogduk N, Mercer S. Biomechanics of the cervical spine 1: normal kinematics. Clin Biomech. 2000;15(9): 633�48. [PubMed]
46. Radcliff K, Kepler C, Reitman C, Harrop J, Vaccaro A. CT and MRI-based diagnosis of craniocervical dislocations the role of the occipitoatlantal ligament. Clin Orthop Rel Res. 2012;70(6): 1602�13. [PMC free article] [PubMed]
47. Hino H, Abumi K, Kanayama M, Kaneda K. Dynamic motion analysis of normal and unstable cervical spines using cineradiography.an in vivo study. Spine (Phila Pa 1976). 1999;24(2): 163�8. [PubMed]
48. Dvorak J, Penning L, Hayek J, Panjabi MM, Grob D, Zehnder R. Functional diagnostics of the cervical spine using computer tomography. Neuroradiology. 1988;30: 132�7. [PubMed]
49. Antinnes J, Dvorak J, Hayek J, Panjabi MM, Grob D. The value of functional computed tomography in the evaluation of soft-tissue injury in the upper cervical spine. Eur Spine J. 1994;3: 98�101. [PubMed]
50. Wilberger JE, Maroon JC. Occult posttraumatic cervical ligamentous instability. J Spinal Disord. 1990;(2): 156�61. [PubMed]
51. Levine A, Edwards CC. Traumatic lesions of the occipitoatlantoaxial complex. Clin Orthop Rel Res. 1989;239: 53�68. [PubMed]
52. Chang H, Gilbertson LG, Goel VK, Winterbottom JM, Clark CR, Patwardhan A. Dynamic response of the occipito-atlanto-axial (C0-C1-C2):complex in right axial rotation. J Orthop Res. 1992;10(3): 446�53. [PubMed]
53. Goel VK, Winterbottom JM, Schulte KR, Chang H , et al. Ligamentous laxity across C0-C1-C2 complex.Axial torque-rotation characteristics until failure. Spine (Phila Pa 1976). 1990;5(10): 990�6. [PubMed]
54. Goel VK, Clark CR, Gallaes K, Liu YK. Moment-rotation relationships of the ligamentous occipito-atlanto-axial complex. J Biomech. 1988;21(8): 673�80. [PubMed]
55. Quinn KP, Winkelstein BA. Cervical facet capsular ligament yield defines the threshold for injury and persistent joint-mediated neck pain. J Biomech. 2007;40(10): 2299�306. [PubMed]
56. Winkelstein BA, Santos DG. An intact facet capsular ligament modulates behavioral sensitivity and spinal glial activation produced by cervical facet joint tension. Spine (Phila Pa 1976). 2008;33(8): 856�62. [PubMed]
57. Stemper BD, Yoganandan N, Pintar FA. Effects of abnormal posture on capsular ligament elongations in a computational model subjected to whiplash loading. J Biomech Eng. 2005;38(6): 1313�23. [PubMed]
58. Ivancic PC, Ito S, Tominaga Y , et al. Whiplash causes increased laxity of cervical capsular ligament. Clin Biomech. 2008;23(2): 159�65. [PMC free article] [PubMed]
59. IASP Spinal pain, section 1: spinal and radicular pain syndromes. http: //www.iasp-pain.org/AM/Template.cfm?Section=Classification _of_Chronic_Pain&Template=/CM/ContentDisplay.cfm&ContentID=16268. Accessed Nov 25. 2013.
60. Argenson C, Lovet J, Sanouiller JL, de Peretti F. Traumatic rotatory displacement of the lower cervical spine. Spine (Phila Pa 1976). 1988;3(7): 767�73. [PubMed]
61. Tominaga Y, Maak TG, Ivancic PC, Panjabi MM, Cunningham BW. Head-turned rear impact causing dynamic cervical intervertebral foraminal narrowing implications for ganglion and nerve root injury. J Neurosurg Spine. 2006;4: 380�7. [PubMed]
62. Caridi JM, Pumberger M, Hughes AP. Cervical radiculopathy a review. HSS J. 2011;7(3): 265�72. [PMC free article] [PubMed]
63. Kirkaldy-Willis HF, Farfan HF. Instability of the lumbar spine. Clin Orthop Rel Res. 1982;(165): 110�23. [PubMed]
64. Voorhies RM. Cervical spondylosis recognition, differential diagnosis, and management. Ochsner J. 2001;3(2): 78�84. [PMC free article] [PubMed]
65. Binder AI. Cervical spondylosis and neck pain. BMJ. 2007;334: 527�31. [PMC free article] [PubMed]
66. Aker PD, Gross AR, Goldsmith CH, Peloso P. Conservative management of mechanical neck pain systematic overview and meta-analysis. BMJ. 1996;313: 1291�6. [PMC free article] [PubMed]
67. McCormack BM, Weinstein PR. Cervical spondylosis an update. West J Med. 1996;165: 43�51. [PMC free article] [PubMed]
68. Peng BG, Hou SX, Shi Q, Jia LS. The relationship between cartilage end-plate calcification and disc degeneration an experimental study. Chin Med J. 2001;114: 308�12. [PubMed]
69. Mauro A, Eisenstein SM, Little C , et al. Are animal models useful for studying human disc disorders/degeneration?. Eur Spine J. 2008;17: 2�19. [PMC free article] [PubMed]
70. Oxland TR, Panjabi MM, Southern EP, Duranceau JS. An anatomic basis for spinal instability a porcine trauma model. J Orthop Res. 1991;9(3): 452�62. [PubMed]
71. Wang JY, Shi Q, Lu WW , et al. Cervical intervertebral disc degeneration induced by unbalanced dynamic and static forces a novel in vivo rat model. Spine (Phila Pa 1976) 2006;Jun 15; 31: 1532�38. [PubMed]
72. Schulte K, Clark CR, Goel VK. Kinematics of the cervical spine following discectomy and stabilization. Spine (Phila Pa 1976). 1989;(10): 1116�21. [PubMed]
73. Kelly MP, Mok JM, Frisch RF, Tay BK. Adjacent segment motion after anterior cervical discectomy and fusion versus prodisc-c cervical total disk arthroplasty analysis from a randomized, controlled trial. Spine (Phila Pa 1976) 2011; 36(15): 1171�9. [PubMed]
74. Bydon M, Xu R, Macki M , et al. Adjacent segment disease after anterior cervical discectomy and fusion in a large series. Neurosurgery. 2014;74: 139�46. [PubMed]
75. Song JS, Choi BW, Song KJ. Risk factors for the development of adjacent segment disease following anterior cervical arthrodesis for degenerative cervical disease comparison between fusion methods. J Clin Neurosci. 2014;21(5): 794�8. [PubMed]
76. Johansson BH. Whiplash injuries can be visible by functional magnetic resonance imaging. Pain Res Manage. 2006;11(3): 197�9. [PMC free article] [PubMed]
77. Swinkels RA, Oostendorp RA. Upper cervical instability fact or fiction. J Manip Physiol Ther. 1996;19(3): 185�94. [PubMed]
78. Barnsley L, Lord S, Bogduk N. Whiplash injury. Pain. 1994;58: 283�307. [PubMed]
79. Spitzer WO, Skovron ML, Salmi LR , et al. Scientific monograph of the Quebec task force on whiplash-associated disorders redefining “whiplash” and its management. Spine (Phila Pa 1976). 1995;20(8) Suppl : 1S�73. [PubMed]
80. Kaale BR, Krakenes J, Albrektsen G, Wester K. Head position and impact direction in whiplash injuries associations with MRI-verified lesions of ligaments and membranes in the upper cervical spine. J Neurotrauma. 2005;22(11): 1294�302. [PubMed]
81. Falco FJ, Erhart S, Wargo BW , et al. Systematic review of diagnostic utility and therapeutic effectiveness of cervical facet joint interventions. Pain Physician. 2009;12(2): 323�44. [PubMed]
82. Winkelstein BA, Nightingale RW, Richardson WJ, Myers BS, editors. Proceedings of the 43rd Stapp Car Crash Conference. Saniego CA.: 1999. Cervical facet joint mechanics its application to whiplash injury.
83. Lee DJ, Winkelstein BA. The failure response of the human cervical facet capsular ligament during facet joint retraction. J Biomech. 2012;45(14): 2325�9. [PubMed]
84. Bogduk N, Yoganandan N. Biomechanics of the cervical spine part 3: minor injuries. Clin Biomech. 2001;16(4): 267�75. [PubMed]
85. Lord SM, Barnsley L, Wallis BJ, Bogduk N. The prevalence of chronic cervical zygapophysial joint pain after whiplash. Spine (Phila Pa 1976). 1995;20(1): 20�5. [PubMed]
86. Lee KE, Davis MB, Mejilla RM, Winkelstein BA. In vivo cervical facet capsule distraction mechanical implications for whiplash and neck pain. Stapp Car Crash J. 2004;48: 373�95. [PubMed]
87. Tominaga Y, Ndu AB, Coe MP , et al. Neck ligament strength is decreased following whiplash trauma. BMC Musculoskelet Disord. 2006;7: 103. [PMC free article] [PubMed]
88. Stokes IA, Frymoyer JW. Segmental motion and instability. Spine (Phila Pa 1976). 1987;7: 688�91. [PubMed]
89. Stokes IA, Iatridis JC. Mechanical conditions that accelerate intervertebral disc degeneration overload versus immobilization. Spine (Phila Pa 1976). 2004;29: 2724�32. [PubMed]
90. Veres SP, Robertson PA, Broom ND. The influence of torsion on disc herniation when combined with flexion. Eur Spine J. 2010;19: 1468�78. [PMC free article] [PubMed]
91. Winkelstein BA, Nightingale RW, Richardson WJ, Myers BS. The cervical facet capsule and its role in whiplash injury a biomechanical investigation. Spine (Phila Pa 1976). 2000;25(10): 1238�46. [PubMed]
92. Siegmund GP, Myers BS, Davis MB, Bohnet HF, Winkelstein BA. Mechanical evidence of cervical facet capsule injury during whiplash a cadaveric study using combined shear, compression, and extension loading. Spine (Phila Pa 1976). 2001;26(19): 2095�101. [PubMed]
93. Siegmund GP, Davis MB, Quinn KP , et al. Head-turned postures increase the risk of cervical facet capsule injury during whiplash. Spine (Phila PA 1976). 2008;33(15): 1643�9. [PubMed]
94. Storvik SG, Stemper BD. Axial head rotation increases facet joint capsular ligament strains in automotive rear impact. Med Bio Eng Comput. 2011;49(2): 153�61. [PubMed]
95. Centers for Disease Control Injury prevention & control traumatic brain injury. http: //www.cdc.gov/TraumaticBrainInjury/statistics. html [Accessed March 4. 2014.
96. Centers for Disease Control Concussion.facts for physicians booklet. http: //www.cdc.gov/concussion/HeadsUp/physicians_too l_kit.html [Accessed March 4. 2014.
97. Giza C, Hovda D. The neurometabolic cascade of concussion. J Athl Train. 2001;36: 228�35. [PMC free article] [PubMed]
98. Cuccurullo S, Elovic E, Baerga E, Cuccurullo S, editors. Demos Medical Publishing: New York; 2004. Mild traumatic brain injury and postconcussive syndrome Physical medicine and rehabilitation board review.
99. Leddy J, Sandhu H, Sodhi V, Baker J, Willer B. Rehabilitation of concussion and post-concussion syndrome. Sports Health. 2012;4(2): 147�54. [PMC free article] [PubMed]
100. ICD-10, International statistical classification of diseases and related health problems 10th revision. World Health Organization. [PubMed]
101. Boake C, McCauley SR, Levin HS , et al. Diagnostic criteria for postconcussional syndrome after mild to moderate traumatic brain injury. J Neuropsych Clin Neurosci. 2005;17: 350�6. [PubMed]
102. Couch Jr, Bears C. Chronic daily headache in the posttrauma syndrome relation to extent of head injury. Headache. 2001;41: 559�64. [PubMed]
103. Barkhoudarian G, Hovda DA, Giza CC. The molecular pathophysiology of concussive brain injury. Clin Sports Med. 2011;30: 33�48. [PubMed]
104. Saari A, Dennison CR, Zhu Q , et al. Compressive follower load influences cervical spine kinematics and kinetics during simulated head-first impact in an in vitro model. J Biomech Eng. 2013;135(11): 111003. [PubMed]
105. Zhou S-W, Guo L-X, Zhang S-Q, Tang C-Y. Study on cervical spine injuries in vehicle side impact. Open Mech Eng J. 2010;4: 29�35.
106. Yoganandan N, Kumaresan S, Pintar FA. Geometric and mechanical properties of human cervical spine ligaments. J Biomech Invest. 2000;122: 623�9. [PubMed]
107. Radanov BP, Sturzenegger M, Distefano G, Schnidrig A, Aljinovic M. Factors influencing recovery from headache after common whiplash. BMJ. 1993;307: 652�5. [PMC free article] [PubMed]
108. Martins J, Pratesi R, Bezerra A. Anatomical relationship between vertebral arteries and cervical vertebrae a computerized tomography study. Int J Morph. 2003;21: 123�9.
109. Cacciola F, Phalke U, Goel A. Vertebral artery in relationship to C1-C2 vertebrae an anatomical study. Neurology India. 2004;52: 178�84. [PubMed]
110. Mitchell JA. Changes in vertebral artery blood flow following normal rotation of the cervical spine. J Manip Physiol Ther. 2003;26: 347�51. [PubMed]
111. Mitchell J. Vertebral artery blood flow velocity changes associated with cervical spine rotation a meta-analysis of the evidence with implications for professional practice. J Man Manip Ther. 2009;17: 46�57. [PMC free article] [PubMed]
112. Haynes M, Hart R, McGeachie J. Vertebral arteries and neck rotation doppler velocimeter interexaminer reliability. Ultrasound Med Biol. 2000;26: 57�62. [PubMed]
113. Kuether TA, Nesbit GM, Clark VM, Barnwell SL. Rotational vertebral artery occlusion a mechanism of vertebrobasilar insufficiency. Neurosurgery. 1997;41: 427�32. [PubMed]
114. Yang PJ, Latack JT, Gabrielsen TO, Knake JE, Gebarski SS, Chandler WF. Rotational vertebral artery occlusion at C1-C2. Am J Neuroradiol. 1985;6: 96�100. [PubMed]
115. Cape RT, Hogan DB. Vertebral-basilar insufficiency. Can Family Physician. 1983;29: 305�8. [PMC free article] [PubMed]
116. Go G, Soon-Hyun H, Park IS, Park H. Rotational vertebral artery compression bow hunter’s syndrome. J Korean Neurosurg Soc. 2013;54: 243�5. [PMC free article] [PubMed]
117. Gordin K, Hauser R. The case for utilizing prolotherapy as a promising stand-alone or adjunctive treatment for over-manipulation syndrome. J Applied Res. 2013;13: 1�28.
118. Endo K, Ichimaru K, Komagata M, Yamamoto K. Cervical vertigo and dizziness after whiplash injury. Eur Spine J. 2006;15: 886�90. [PMC free article] [PubMed]
119. Creighton D, Kondratek M, Krauss J, Huijbregts P, Qu H. Ultrasound analysis of the vertebral artery during non-thrust cervical translatoric spinal manipulation. J Man Manip Ther. 2011;19: 84�90. [PMC free article] [PubMed]
120. Inamasu J, Nakatsukasa M. Rotational vertebral artery occlusion associated with occipitoatlantal assimilation, atlantoaxial subluxation and basilar impression. Clin Neurol Neurosurg. 2013;115: 1520�3. [PubMed]
121. Kim HA, Yi HA, Lee CY, Lee H. Origin of isolated vertigo in rotational vertebral artery syndrome. Neuro Sci. 2011;32: 1203�7. [PubMed]
122. Yacovino DA1, Hain TC. Clinical characteristics of cervicogenic related dizziness and vertigo. Sem Neurol. 2013;33: 244�55. [PubMed]
123. Limousin CA. Foramen arcuale and syndrome of Barr�-Li�ou. Int Orthop. 1980;4(1): 19�23. [PubMed]
124. Pearce J. Barr�-Li�ou �syndrome�. J Neurol Neurosurg Psychol. 2004;75(2): 319. [PMC free article] [PubMed]
125. Hackett GS, Huang TC, Raferty A. Prolotherapy for headache; pain in the head and neck, and neuritis. Headache. 1962:3�11. [PubMed]
126. Tamura T. Cranial symptoms after cervical injury.Aetiology and treatment of the Barr -Li ou syndrome. J Bone Joint Surg Br. 1989;71B:282�7. [PubMed]
127. Qian J, Tian Y, Qiu GX, Hu JH. Dynamic radiographic analysis of sympathetic cervical spondylosis instability. Chin Med Sci J. 2009;24: 46�9. [PubMed]
128. Humphreys BK, Peterson C. Comparison of outcomes in neck pain patients with and without dizziness undergoing chiropractic treatment a prospective cohort study with 6 month follow-up. Chiropr Man Ther. 2013;21(1): 3. [PMC free article] [PubMed]
129. Pintar FA, Yoganandan N, Myers T, Elhagediab A, Sances A ., Jr Biomechanical properties of human lumbar spine ligaments. J Biomech. 1992;25: 1351�6. [PubMed]
130. Yoganandan N, Pintar D, Maiman J, Cusick JF, Sances A , Jr, Walsh PR. Human head-neck biomechanics under axial tension. Med Eng Phys. 1996;18: 289�94. [PubMed]
131. Mc Lain R. Mechanoreceptors endings in human cervical facet joints. Iowa Orthop J. 1993;13: 149�54. [PMC free article] [PubMed]
132. Steindler A, Luck J. Differential diagnosis of pain low in the back allocation of the source of pain by the procaine hydrochloride method. JAMA. 1938;110: 106�13.
133. Donelson R, Aprill C, Medcalf R, Grant W. A prospective study of centralization of lumbar and referred pain a predictor of symptomatic discs and anular competence. Diagn Ther. 1997;22: 1115�22. [PubMed]
134. Meleger AL, Krivickas LS. Neck and back pain musculoskeletal disorders. Neurol Clin. 2007;25: 419�38. [PubMed]
135. Silver P. Direct observation of changes in tension in the supraspinous and interspinous ligaments during flexion and extension of the vertebral column in man. J Anat. 1954:550�1.
136. Nachemson A. Lumbar intradiscal pressure.Experimental studies on post-mortem material. Acta Orthop Scand. 1960;43S:1�104. [PubMed]
137. Galante J. Tensile properties of the human lumbar annulus fibrosus. Acta Orthop Scand. 1967;100S:1�91. [PubMed]
138. Stokes IA. Surface strain on human intervertebral discs. J Orthop Res. 1987;5: 348�55. [PubMed]
139. Stokes IA. Bulging of the lumbar intervertebral discs non-contacting measurements of anatomical specimens. J Spinal Disord. 1988;1: 189�93. [PubMed]
140. Manchikanti L, Malla Y, Cash KA, McManus CD, Pampati V. Fluoroscopic cervical interlaminar epidural injections in managing chronic pain of cervical postsurgery syndrome preliminary results of a randomized, double-blind, active control trial. Pain Physician. 2012;15: 13�26. [PubMed]
141. Manchikanti L, Singh V, Falco FJE, Cash KA, Fellows B. Comparative outcomes of a 2-year follow-up of cervical medial branch blocks in management of chronic neck pain a randomized, double-blind controlled trial. Pain Physician. 2010;13: 437�50. [PubMed]
142. Falco FJE, Manchikanti L, Datta S , et al. Systematic review of the therapeutic effectiveness of cervical facet joint interventions an update. Pain Physician. 2012;15: E839�68. [PubMed]
143. Benyamin R, Singh V, Parr AT, Conn A, Diwan S, Abdi S. Systematic review of the effectiveness of cervical epidurals in the management of chronic neck pain. Pain Physician. 2009;12: 137�57. [PubMed]
144. Sherman KJ, Cherkin DC, Hawkes RJ, Miglioretti DL, Deyo RA. Randomized trial of therapeutic massage for chronic neck pain. Clin J Pain. 2009;25(3): 233�8. [PMC free article] [PubMed]
145. Matsubara T, Arai Y-CP, Shiro Y , et al. Comparative effects of acupressure at local and distal acupuncture points on pain conditions and autonomic function in females with chronic neck pain. Evidence-Based Complementary Alternative Med. 2011; 2011: 543921. [PMC free article] [PubMed]
146. Manchikanti L, Cash KA, Pampati V, Wargo BW, Malla Y. A randomized, double-blind, active control trial of fluoroscopic cervical interlaminar epidural injections in chronic pain of cervical disc herniation results of a 2-year follow-up. Pain Physician. 2013;16: 465�78. [PubMed]
147. Peloso PM, Khan M, Gross AR , et al. Pharmacological interventions including medical injections for neck pain an overview as part of the ICON project. Open Orthop J. 2013;7(Suppl 4 M8 ): 473�93. [PMC free article] [PubMed]
148. Teasell RW, McClure JA, Walton D, Pretty J , et al. A research synthesis of therapeutic interventions for whiplash-associated disorder (WAD): part 2 – interventions for acute WAD. Pain Res Manage. 2010;15(5): 295�304. [PMC free article] [PubMed]
149. Teasell RW, McClure JA, Walton D , et al. A research synthesis of therapeutic interventions for whiplash-associated disorder (WAD): part 3 – interventions for subacute WAD. Pain Res Manag. 2010;15(5): 305�12. [PMC free article] [PubMed]
150. Teasell RW, McClure JA, Walton D , et al. A research synthesis of therapeutic interventions for whiplash-associated disorder (WAD): part 4 -noninvasive interventions for chronic WAD. Pain Res Manag. 2010;15(5): 313�22. [PMC free article] [PubMed]
151. Teasell RW, McClure JA, Walton D , et al. A research synthesis of therapeutic interventions for whiplash-associated disorder (WAD): part 5 – surgical and injection-based interventions for chronic WAD. Pain Res Manag. 2010;15(5): 323�34. [PMC free article] [PubMed]
152. Linetsky FS, Manchikanti L. Regenerative injection therapy for axial pain. Tech Reg Anaesh Pain Manag. 2005;9: 40�9.
153. Hackett G, editor. Oak Park IL. 5th ed. 1993. Ligament and tendon relaxation treated by prolotherapy ; pp. 94�6.
154. Goswami A. Prolotherapy. J Pain Palliative Care Pharmacother. 2012;26: 376�8. [PubMed]
155. Hauser RA, Maddela HS, Alderman D , et al. Journal of Prolotherapy international medical editorial board consensus statement on the use of prolotherapy for musculoskeletal pain. J Prolotherapy. 2011;3: 744�6.
156. Kim J. The effect of prolotherapy for osteoarthritis of the knee. J Korean Ac Rehab Med. 2002;26: 445�8.
157. Rabago D, Slattengren A, Zgierska A. Prolotherapy in primary care practice. Primary Care. 2010;37: 65�80. [PMC free article] [PubMed]
158. Distel LM, Best TM. Prolotherapy a clinical review of its role in treating chronic musculoskeletal pain. PMR. 2011;3(6) Suppl1 : S78�81. [PubMed]
159. Hackett G. Prolotherapy in whiplash and low back pain. Postgrad Med. 1960:214�9. [PubMed]
160. Kafetz D. Whiplash injury and other ligamentous headache – its management with prolotherapy. Headache. 1963;3: 21�8. [PubMed]
161. Hauser RA, Hauser MA. Dextrose prolotherapy for unresolved neck pain an observational study of patients with unresolved neck pain who were treated with dextrose prolotherapy at an outpatient charity clinic in rural Illinois. Pract Pain Manage. 2007;10: 56�69.
162. Hooper RA, Frizzell JB, Faris P. Case series on chronic whiplash related neck pain treated with intraarticular zygapophysial joint regeneration injection therapy. Pain Physician. 2007;10: 313�8. [PubMed]
163. Centeno CJ, Elliott J, Elkins WL, Freeman M. Fluoroscopically guided cervical prolotherapy for instability with blinded pre and post radiographic reading. Pain Physician. 2005;8(1): 67�72. [PubMed]
164. Lee J, Lee HG, Jeong CW, Kim CM, Yoon MH. Effects of intraarticular prolotherapy on sacroiliac joint pain. Korean J Pain. 2009:229�33.
165. Cusi M, Saunders J, Hungerford B, Wisbey-Roth T, Lucas P, Wilson S. The use of prolotherapy in the sacroiliac joint. Brit J Sports Med. 2010;44: 100�4. [PubMed]
166. Naeim F, Froetscher L, Hirschberg GG. Treatment of chronic iliolumbar syndrome by infiltration of the iliolumbar ligament. West J Med. 1982;136: 372�4. [PMC free article] [PubMed]
167. Kim J. Effects of prolotherapy on knee joint pain due to ligament laxity. J Korean Pain Soc. 2004;17: 47�5.
168. Reeves K, Hassanein KM. Long-term effects of dextrose prolotherapy for anterior cruciate laxity. Alternative Ther. 2003;9: 58�62. [PubMed]
169. Jo D. Effects of prolotherapy on knee joint pain due to ligament laxity. J Korean Pain Soc. 2004;17: 47�50.
170. Kim S. Effects of prolotherapy on chronic musculoskeletal disease. Korean J Pain. 2002;15: 121�5.
171. Wheaton MT, Jensen N. The ligament injury-osteoarthritis connection the role of prolotherapy in ligament repair and the prevention of osteoarthritis. J Prolotherapy. 2011;3: 790�812.
172. Refai H, Altahhan O, Elsharkawy R. The efficacy of dextrose prolotherapy for temporomandibular joint hypermobility a preliminary prospective, randomized double-blind, placebo-controlled clinical trial. J Oral Maxillofac Surg. 2011;69(12): 2962�70. [PubMed]
173. Hauser R, Phillips HJ. Treatment of joint hypermobility syndrome, including Ehlers-Danlos syndrome, with Hackett-Hemwall prolotherapy. J Prolotherapy. 2011;3: 612�29.
174. Hackett G. Joint stabilization an experimental, histologic study with comments on the clinical application in ligament proliferation. Am J Surg. 1955;89: 967�73. [PubMed]
175. Liu Y, Tipton C, Matthes R, Bedford TG, Maynard JA, Walmer HC. An in situ study of the influence of a sclerosing solution in rabbit medial collateral ligaments and its junction strength. Connect Tissue Res. 1983;11: 95�102. [PubMed]
176. Klein R, Dorman T, Johnson C. Proliferant injections for low back pain histologic changes of injected ligaments and objective measurements of lumbar spine mobility before and after treatment. J Neuro Ortho Med Surg. 1989;10: 123�6.
177. Auburn A, Benjamin S, Bechtel R, Matthews S. Increase in cross sectional area of the iliolumbar ligament using prolotherapy agents an ultrasonic case study. J Prolotherapy. 1999;1: 156�62.
178. Linetsky FS, Miguel R, Torres F. Treatment of cervicothoracic pain and cervicogenic headaches with regenerative injection therapy. Curr Pain Headache Rep. 2004;8(1): 41�8. [PubMed]
179. Alderman D. Prolotherapy for knee pain. Pract Pain Manage. 2007;7(6): 70�9.
180. Hooper RA, Yelland M, Fonstad P, Southern D. Prospective case series of litigants and non-litigants with chronic spinal pain treated with dextrose prolotherapy. Int Musculoskelet Med. 2011;33: 15�20.
181. Hauser RA. A retrospective study on Hackett-Hemwall dextrose prolotherapy for chronic shoulder pain at an outpatient charity clinic in rural Illinois. J Prolotherapy. 2009;4: 205�16.
182. Hauser RA, Hauser MA, Holian P. Hackett-Hemwall dextrose prolotherapy for unresolved elbow pain. Pract Pain Manage. 2009:14�26.
183. Hauser RA. Dextrose prolotherapy for unresolved low back pain a retrospective case series study. J Prolotherapy. 2009;3: 145�55.
184. Hauser RA. A retrospective study on Hackett-Hemwall dextrose prolotherapy for chronic hip pain at an outpatient charity clinic in rural Illinois. J Prolotherapy. 2009;(2): 76�88.
185. Hauser RA. A retrospective study on dextrose prolotherapy for unresolved knee pain at an outpatient charity clinic in rural Illinois. J Prolotherapy. 2009;(1): 11�21.
186. Hauser R, Woldin B. Treating osteoarthritic joints using dextrose prolotherapy and direct bone marrow aspirate injection therapy. Open Arthritis J. 2014;7: 1�9.
Close Accordion
How Chiropractic Treatment Evolved in Healthcare | Eastside Chiropractor

How Chiropractic Treatment Evolved in Healthcare | Eastside Chiropractor

The treatment benefits of spinal manipulation for musculoskeletal injuries and conditions were contested in the early days of chiropractic. Chiropractic has been accepted for the treatment of back pain, neck pain, sciatica, joint problems, sprains, strains, osteoarthritis, herniated disks as well as for other musculoskeletal (MSK) injuries and conditions.

 

Is chiropractic care safe and effective for chronic pain?

 

Scientific evidence has suggested that spinal manipulation is a secure, mild-to-moderate pain reliever for lower back pain, neck pain and headache, and recent health care guidelines have recorded it as a viable treatment option for symptoms that don’t react to self-care. Chiropractic care is now a popular form of alternative treatment.

 

The Evolution of Chiropractic Care

 

Spinal manipulation in chiropractic medicine has developed greatly since the very first high-velocity adjustment performed by D.D. Palmer in the late 1800s. In addition, chiropractors have started to adopt various other evidence-based approaches to spine issues. Now, techniques include several other forms of chiropractic adjustments and manual manipulations, as well as low-velocity adjustments involving the hands and machines and instruments.

 

Modern chiropractic studies have started to concentrate more on the effectiveness of particular types of spinal manipulation, such as when specific adjustments are performed and how long they are included as a member of chiropractic therapy plans. Besides chiropractors, Doctors of Osteopathic Medicine (DO) plus some Medical Doctors (MD) and Physical Therapists (PT) additionally perform spinal adjustments and manipulations.

 

Concerns about the safety of manipulating the cervical spine for neck pain have been increased in regard to strokes. However, the medical literature does not substantiate that the risk increases or causes strokes, but instead suggests that the reported stroke cases were individuals who already had indications of impending stroke. The literature shows no difference in stroke incidence, regardless if someone reports that acupuncture is generally and equally as safe of a treatment for neck pain as other non invasive care, and sees a Medical Doctor or Doctor of Chiropractic.

 

Other Chiropractic Treatments Besides Manipulation

 

Chiropractic health care has also grown beyond spinal manipulation to add other manual treatment such as soft-tissue mobilization and massage, instrument-assisted soft tissue mobilization, the McKenzie approach to mechanical diagnosis and therapy, as well as stabilization and strength training exercise, nourishment and postural programs, along with also the incorporation of some cognitive-behavioral circumstance to treatment regimens.

 

The appropriateness and efficacy of some newer treatments (such as spinal decompression) used by some chiropractors are a subject of disagreement among chiropractors and others, as are some other more recent developments, including treating children with spinal manipulation and marketing chiropractic as a holistic therapy for asthma, allergies, acid reflux, digestive disorders, ear infections, colic and other ailments that are less commonly treated with spinal manipulation. It’s important for patients to communicate with their healthcare specialists accordingly.

 

Modern Recognition of Chiropractic

 

Eighteen years following its founding in the United States, acupuncture obtained its first state licensing from 1913. In the 18 years, chiropractic medicine became recognized in 39 states. Chiropractic is now recognized as a healthcare profession in not just all 50 states but the District of Columbia, Puerto Rico, U.S. Virgin Islands and several other nations. Chiropractic schools are to Canada and the United States.

 

Chiropractic licensing is handled on a state-by-state foundation based on specific state laws. There are now more than 60,000 licensed chiropractors in the United States, making chiropractic the third largest degree health care profession.

 

Efficacy of Chiropractic Treatment

 

A 2007 survey estimated that over 18 million adults (8 percent of their U.S. adult inhabitants) and two million children (nearly 3 percent of American kids) visited a doctor. Chiropractic may be fully or partially covered by private insurance programs, and Medicare may cover manual manipulation for subluxation of the spine in certain conditions.

 

A 2009 evidence-based report on population, health and overall healthcare spending implied that chiropractic care of back pain and neck pain supplies greater satisfaction, superior outcomes and much more cost-effectiveness than other commonly-utilized neck and back pain treatments, which can consist of easy rest, medications, surgery and more.

 

This report also reviewed the scientific literature about chiropractic care, that has been noted in other findings to be at least as successful as other widely-used therapies for lower back pain and more effective (when combined with exercise) compared to other common treatments for neck pain. An additional review of scientific literature suggested that patients with psychiatric coverage as part of their insurance benefits had lower prices and reduced imaging studies, fewer hospitalizations and less surgeries than patients without chiropractic included in their insurance.

 

Today, chiropractors like hospital statements in many hospitals, clinic in multidisciplinary practices, work inside the Department of Defense (DoD) and Veterans Affairs (VA) systems, and cure both Medicare and Medicaid patients. The profession continues to become integrated and more mainstream.

 

The scope of our information is limited to chiropractic and spinal injuries and conditions. To discuss options on the subject matter, please feel free to ask Dr. Jimenez or contact us at 915-850-0900 .
By Dr. Alex Jimenez

 

Additional Topics: Wellness

 

Overall health and wellness are essential towards maintaining the proper mental and physical balance in the body. From eating a balanced nutrition as well as exercising and participating in physical activities, to sleeping a healthy amount of time on a regular basis, following the best health and wellness tips can ultimately help maintain overall well-being. Eating plenty of fruits and vegetables can go a long way towards helping people become healthy.

 

blog picture of cartoon paperboy big news

 

TRENDING TOPIC: EXTRA EXTRA: About Chiropractic

 

 

Chiropractic Manipulation for Cervical Spine Issues | Eastside Chiropractor

Chiropractic Manipulation for Cervical Spine Issues | Eastside Chiropractor

The manipulation of the cervical spine or neck is a common technique utilized by doctors of chiropractic for individuals complaining of upper back, neck, and shoulder/arm pain, in addition to headaches.

 

What is the benefit of cervical spinal manipulation?

 

Similar to the treatment for many injuries and/or conditions which affect the thoracic and lumbar spine, or back, chiropractic treatment is thought of as a first line of therapy for a range of cervical spine conditions.

 

Chiropractic treatment aiming for cervical spine pain management include (but aren’t limited to) a mix of:

 

  • Reducing pain
  • Improving movement
  • Restoring function into the head and neck region

 

Patients must be advised that the treatment will start after a complete patient history, physical examination, review of past, family histories, and review of systems are completed. Tests might include X-ray, CT, MRI, EMG/NCV, urine analysis and lab blood, referral to a professional, more, depending on each individual case demonstration.

 

Different Types of Chiropractic Manipulation

 

There are two general manipulation approaches for spine ailments:

 

  • Cervical spinal manipulation – frequently thought of as the conventional chiropractic adjustment, or even a high-velocity, low-amplitude (HVLA) technique
  • Cervical spinal mobilization – which can be a more gentle/less forceful modification, or even a low-velocity, low-amplitude (LVLA) technique moving the joint through a tolerable range of movement.

 

The combination of the many approaches varies from patient to patient depending on the healthcare professional’s preferred tactics and tastes, the patient’s comfort and tastes, and the patient’s response to the treatment, in addition to both previous experience and observations made during the course of therapy.

 

Chiropractors may also use therapy to treat other cervical spine complaints. Adjunctive therapies may include therapeutic heat program, massage exercises, and more. Chiropractic manipulation can handle numerous causes of neck pain. It’s not a cure for every single type of neck problem. Two causes of pain which originate in the neck and may be treated by manipulation comprise of mechanical neck pain and disc problems.

 

Mechanical Neck Pain

 

Mechanical neck pain comprises of pain associated with the tendons, joint capsules, ligaments and/or the fascia. This type of issue is a frequent cause of neck pain and stiffness.� Facet joint issues are a well-known case of mechanical neck pain. The facets are located in the back of the neck. If a facet joint is hurt or sprained, pain may be localized or may radiate along other upper extremities. The pain pattern depends upon the specific level and is unique.

 

Cervical Disc Issues

 

Tears may develop in the cervical disc and/or the inside of the disc (the nucleus) may herniate through the outer area (the annulus) and trap or pinch the nerve root as it leaves the spine.

 

Cervical nerve root irritation can frequently refer pain down the arm and into the hand, typically affecting particular areas like the 4th and 5th digits, the palms side thumb to 3rd fingers and/or the back of the hands on the thumb, index finger side of the hand, depending on which nerve root is irritated.

 

On rare occasions, if the nucleus of the disc herniates straight backward, it can compress the spinal cord and create symptoms in the legs and also impact the function of the bowels and/or bladder. On such occasions, the patient needs to be referred to a spine surgeon to get prompt care.

 

These are two examples of types of cervical spine conditions which may be treated with spinal manipulation. The patient needs to receive a whole exam prior to receiving any kind of manipulation.

 

The scope of our information is limited to chiropractic and spinal injuries and conditions. To discuss options on the subject matter, please feel free to ask Dr. Jimenez or contact us at 915-850-0900 .
By Dr. Alex Jimenez

 

Additional Topics: Wellness

 

Overall health and wellness are essential towards maintaining the proper mental and physical balance in the body. From eating a balanced nutrition as well as exercising and participating in physical activities, to sleeping a healthy amount of time on a regular basis, following the best health and wellness tips can ultimately help maintain overall well-being. Eating plenty of fruits and vegetables can go a long way towards helping people become healthy.

 

blog picture of cartoon paperboy big news

 

TRENDING TOPIC: EXTRA EXTRA: About Chiropractic

 

 

When Neck Cracking Needs Medical Attention | Eastside Chiropractor

When Neck Cracking Needs Medical Attention | Eastside Chiropractor

It’s a frequent occurrence: You twist or tilt your head to the side and your neck cracks. You could be asking yourself why your neck does that but more importantly, is it something to be concerned about?

 

Rest assured that, typically, neck-cracking is nothing to worry about. However, there are a few exceptions when popping in the neck may be an indication of a more serious issue. It’s worth learning about the signs of unhealthy neck cracking.

 

Crepitus: Benign Joint Cracking

 

Whenever a joint in the body creates a cracking, popping, or grinding sound or feeling, this is referred to as crepitus. Experts think that crepitus is caused by gas bubbles in the synovial fluid of the joint being formed or bursting. Crepitus is considered benign, and studies haven’t shown any signs that it may cause joint damage or raise risk for arthritis.

 

A surefire indication that a neck crack is the end result of crepitus would be to repeat the motion that caused it and see if it happens again. Otherwise, the crack was probably crepitus. It requires about 20 minutes to the gas bubbles to reform.

 

When Neck Cracking Becomes a Concern

 

Generally speaking, neck cracking probably does not indicate a problem. However, a doctor ought to be consulted if neck cracking communicates some of the following symptoms:

 

  • Pain or swelling. Neck crepitus with pain or swelling could indicate osteoarthritis or some other kind of process .
  • Recent accident or injury. If the neck is creating new cracking or grinding sounds after trauma following a car crash or a fall, then that may signal a structural change which may need proper care.
  • Frequent or constant. If the neck crepitus is continuous, the joint is moved, then that could signal an issue in function, especially when accompanied by pain.
  • Recent surgery. Sometimes the neck develops crepitus after surgery in the cervical spinal column. While they could be normal and nothing to worry about, hey need to be mentioned to the surgeon in case.

 

Could Neck Cracking Cause More Serious Issues?

 

Some individuals regularly crack their neck on purpose, either due to a nervous habit or perhaps to bring some therapeutic relief from neck tightness. As such, it’s typical for people to wonder if by cracking the neck, the joints can be worn down and lead to arthritis.

 

The medical literature indicates that repeatedly cracking the neck, or some of the synovial joints throughout the body, doesn’t increase an individual’s risk for developing arthritis at those joints. Some studies suggest negative effects, such as loosened ligaments, could potentially result from this, however.

 

While quite infrequent, there are reports of vertebral artery dissection leading to a stroke following specific forms of manipulation of the cervical spine. This is likely to happen if the patient seeks treatment from a health care professional who doesn’t practice spinal manipulation. As a normal precaution, anyone experiencing concerning symptoms like nausea, nausea, lightheadedness, numbness, tingling, or other troubling symptoms not listed here, should consult with a qualified medical professional immediately.

 

The scope of our information is limited to chiropractic and spinal injuries and conditions. To discuss options on the subject matter, please feel free to ask Dr. Jimenez or contact us at 915-850-0900
 

By Dr. Alex Jimenez

 

Additional Topics: Wellness

 

Overall health and wellness are essential towards maintaining the proper mental and physical balance in the body. From eating a balanced nutrition as well as exercising and participating in physical activities, to sleeping a healthy amount of time on a regular basis, following the best health and wellness tips can ultimately help maintain overall well-being. Eating plenty of fruits and vegetables can go a long way towards helping people become healthy.

blog picture of cartoon paperboy big news

 

TRENDING TOPIC: EXTRA EXTRA: About Chiropractic

 

 

Cervicogenic Headaches Associated with Neck Issues

Cervicogenic Headaches Associated with Neck Issues

A cervicogenic headache begins in the cervical spine, or the neck. Sometimes these headaches mimic migraine headache symptoms. Initially, discomfort may start intermittently, spread to one side (unilateral) of the individual head, and become nearly continuous. Furthermore, pain can be exacerbated by neck movements or a particular neck place (eg, eyes centered on a pc monitor).

Possible Causes of Cervicogenic Headaches

The trigger of a headache is often associated to extreme tension to the neck. The headache may be a consequence of cervical osteoarthritis, a broken disc, or whiplash-type movements that irritates or compresses a cervical nerve. The neck’s bony structures (eg, aspect joints) and its delicate tissues (eg, muscles) can give rise to the improvement of a cervicogenic headache.

Nervous System Function

Certain nerves structures are involved in several cervicogenic headaches. Spinal nerves are signal transmitters that allow the body via the spinal cord and communication between the brain. At each level of the cervical spine is one on the right of the spine and a set of nerves; one on the left side. C1, C2 or C3 may be involved in development of cervicogenic headaches because these nerves permit function (motion) and feeling of the head and neck. Compression can cause pain and inflammation.

Cervicogenic Headache Symptoms

A cervicogenic headache provides in base and the back of the skull as a steady, non-throbbing pain, sometimes extending downward into the neck and between the shoulder-blades. Pain could be felt behind forehead and the brow, although the problem originates in the cervical spine.

Pain usually starts after a sudden neck movements, such as a sneeze. Along with head and neck discomfort, signs may include:

  • Stiff neck
  • Nausea and/or vomiting
  • Dizziness
  • Vision
  • Sensitivity to light or sound
  • Pain in both arms or one

Risk facets that will be engaged in headache on set or irritate cervicogenic headaches include:

  • Fatigue
  • Sleep difficulties
  • Disc problems
  • Current or neck injuries that are preceding
  • Poor posture
  • Muscular stress

Diagnosis of Cervicogenic Headaches

The analysis of a headache commences using a thorough medical background using a physical and neurological evaluation. Diagnostic testing may include:

  • X-rays
  • Magnetic resonance imaging (MRI)
  • CT Scans (rarely)
  • Nerve block injections to validate the diagnosis, cause

Treatment for Cervicogenic Headaches

Initially, your doctor may advise an over-the counter nonsteroidal anti inflammatory drug (eg, aspirin, Aleve). If this is ineffective, then a prescription anti-irritation and pain reliever might be prescribed. Other treatment options, outlined in purchase of from non-invasive to invasive, include:

  • Spinal manipulation or alternative manual therapies
  • Behavioral methods (eg, bio feedback)
  • Acupuncture
  • Trigger level injections
  • Prolotherapy
  • Facet joint blocks (a type of spinal joint injection)
  • Nerve blocks (this is generally of the medial branches of the nerves that provide you with the the facet joints)
  • Radiofrequency pulse ganglionotomy of the nerve root (eg, C 2, C-3)
  • Spine surgery to reduce nerve or vascular compression (this is rarely necessary)

The scope of our information is limited to chiropractic and spinal injuries and conditions. To discuss options on the subject matter, please feel free to ask Dr. Jimenez or contact us at 915-850-0900 .�Green-Call-Now-Button-24H-150x150.png

By Dr. Alex Jimenez

Additional Topics: Cervicogenic Headache and Chiropractic

Neck pain associated with whiplash-associated disorders resulting from an automobile accident are reportedly the most prevalent cause for discomfort along the cervical spine. The sheer force of an impact from a rear-end car crash or other traffic incident can cause injuries or aggravate a previously existing condition. While neck pain is commonly the result of damage to the complex structures of the neck, cervicogenic headaches may also result due to neck issues. Chiropractic care can help carefully restore the alignment of the cervical spine to relieve headaches and neck pain.

blog picture of cartoon paperboy big news

 

TRENDING TOPIC: EXTRA EXTRA: New PUSH 24/7�? Fitness Center

 

 

Atlas Orthogonal Chiropractic For Headaches And Migraines

Atlas Orthogonal Chiropractic For Headaches And Migraines

Manual manipulations and spinal adjustments have been demonstrated to be successful treatment alternatives for patient’s with headaches.

Chiropractic’s capability to correct bio-mechanical dysfunctions can help eliminate common factors which may lead to head and neck pain. A majority of headaches are associated with neck pain and other cervical spine issues, best known as cervicogenic headaches. These headaches are musculo-skeletal in nature and are related to tension headaches, which may also relate to migraines.

According to some research studies, there’s less risk of further injury or aggravation of a previous condition through chiropractic adjustments than with popular medical remedies. Additionally, newest research indicates that nine percent of men and 12 percent of women in the United States experience at least one to two headaches per month, with four percent of the population experiencing more regular headaches.

Prevalence of Head Pain & Neck Pain

Two-thirds of all adult males and greater than 80 percent of females in developed countries suffer from persistent headaches, according to the World Wellness Organization (WHO). Headaches are just as harmful in developing nations as well, primarily because such are not considered to be a symptom of disease. WHO estimates that about half of the individuals who experience headaches never receive any treatment for them.

People who suffer from chronic, everyday headaches amount to about four or five percent of the world’s population, surpassing the percentage of several other common illnesses. Experts genuinely believe the connection of headache victims to those with disabilities is approximately the same.

Headaches are so frequent that Americans pay more than one billion annually to get alleviation from them. Medical expenses plus lost-work time and productivity accounts for an estimated $50 billion in losses for American companies. Just as troubling: The discomfort associated with headaches and migraines might be so extreme, it’s often reported that mental illness follows soon after.

Approximately 95 percent of headaches are categorized as stress, migraine, or cervicogenic, originating in the neck. Symptoms include head pain on either side of the head or a stiff feeling in the neck, along with tightness and soreness. A small percentage of headaches is on the array that is more hazardous and it’s possible for these to need further referral to appropriate healthcare professionals to treat them as necessary.

Treatment for Headaches Associated with Neck Pain

By utilizing risk-free and beneficial treatment protocols, many doctors of chiropractic, or DCs, effortlessly help many individuals reduce the symptoms of headaches. A spinal adjustment can certainly help lessen the strain being placed on the spine and its surrounding structures, such as muscles, tendons, ligaments and blood vessels, diminishing the signs of a headache and allowing for better function.

Particularly as it relates to neck modifying, many people have worries about chiropractic manipulation. Atlas Orthogonal chiropractic is a different kind of chiropractic treatment which is performed without manipulation of the head or neck. The �snap,� �crack,� or �pop� sound usually associated with chiropractic or osteopathic manipulation is not necessary to move a vertebra, especially the atlas or upper cervical joint complex.

Chiropractors in general are perhaps not taught aggressive, forceful techniques; the type that’ll injure vessels or tissues. Chiropractors are taught to use speed and finesse as an alternative to pressure. When the physician performing the procedure compensates for slow-pace by increasing pressure in the manipulation, problems can occur.�Chiropractors provide by far the greatest number of manipulations to the spine than any other profession, but other healthcare professionals can also perform manipulation and mobilization techniques.

Chiropractic health practitioners have had the same simple coaching as any other primary care physician. The variation between DCs and MDs lies in their treatment protocols for certain types of injuries and/or conditions.

Conclusive Findings

The need to seek assistance in emergencies is essential, if all other choices happen to be explored. When seeking specific treatment for cervicogenic headaches as well as neck pain, it’s suggested to seek medical attention with Atlas Orthogonal chiropractic, followed closely by other actions that are less-invasive. Surgery is often suggested and recommended to be used as a last option unless otherwise necessary.

Most people that have had an Atlas Orthogonal chiropractic adjustment report feeling as either a puff of force or nothing at all. They hear a tiny tap and they describe feeling the neck’s tightness and soreness decrease. Some explain the experience as initially underwhelming.� Others report a wave like feeling rushing through the body, especially after various treatments. The healthcare professional�may determine substantial changes between his objective findings from before the adjustment and those he finds afterwards in the patients.

About the Atlas Orthogonal Chiropractic Technique

Atlas Orthogonal chiropractic therapy could be an excellent instrument in the prevention of headaches, accidents and several other problems and includes a calming outcome for many individuals.

The scope of our information is limited to chiropractic and spinal injuries and conditions. To discuss options on the subject matter, please feel free to ask Dr. Jimenez or contact us at 915-850-0900 .�Green-Call-Now-Button-24H-150x150.png

By Dr. Alex Jimenez

Additional Topics: Cervicogenic Headache and Chiropractic

Neck pain associated with whiplash-associated disorders resulting from an automobile accident are reportedly the most prevalent cause for discomfort along the cervical spine. The sheer force of an impact from a rear-end car crash or other traffic incident can cause injuries or aggravate a previously existing condition. While neck pain is commonly the result of damage to the complex structures of the neck, cervicogenic headaches may also result due to neck issues. Chiropractic care can help carefully restore the alignment of the cervical spine to relieve headaches and neck pain.

 

blog picture of cartoon paperboy big news

 

TRENDING TOPIC: EXTRA EXTRA: New PUSH 24/7�? Fitness Center

 

 

Benefits of Atlas Orthogonal Chiropractic Therapy

Benefits of Atlas Orthogonal Chiropractic Therapy

The Atlas Orthogonal chiropractic therapy is a specialization within the field of chiropractic. It’s widely recognized as a safe and effective form of treatment which helps restore the natural integrity of the body. This technique aids to re-activate the body’s natural healing abilities.

The atlas is the top, upper vertebrae of the spine in which the head sits on, connecting the skull and the spine. Orthogonal means at right angles, or square. The atlas must be leveled, or square, on the cervical spine, or neck, and the head must be square, or leveled on the atlas.

If the atlas becomes misaligned, or subluxated, it can cause the head to tilt. As a result of the altered posture, the body will instinctively try to straighten the head up by compensating the posture of the spine while also trying to maintain the proper center of gravity on the body. This however, can create on the spine, adding stress throughout the shoulders, the pelvis, the hips, the knees, and the ankles.

Subluxations, or misalignments, can ultimately be deceiving. People often report experiencing symptoms of pain and discomfort along their back, shoulders, arms and legs while the source of their symptoms often originates along the cervical spine or neck.

The Atlas Vertebral Segment

Specialty of the Atlas Orthogonal

The Atlas Orthogonal chiropractic therapy involves gentler adjustment techniques than traditional chiropractic adjustments, where no intense manipulations are required. The Atlas Orthogonal chiropractic technique utilizes an adjusting instrument developed by Dr. Roy W. Sweat with the aid of engineers at Georgia Tech University. The precision of the Atlas Orthogonal Instrument allows for an adjustment with specifically gentle pressure, one which differs from general chiropractic manipulations.

Atlas Orthogonal recognizes the whole influence that the health of the upper cervical spine has on overall structure and function. It is now believed that input into the brain from the spinal buildings is the primary impact on health which chiropractic helps.

This input is what seems to balance specific manual pressure input, through high velocity. This impact is perhaps greatest at the occipito-atlanto-axial joint complex. That’s, the occiput, or base of the skull, on the atlas, which comes in contact with the second vertebra in the cervical spine, or the axis. When the atlas is subluxated, misaligned or shifted, adversely affecting the nerves, further complications may develop.

How the Atlas Orthogonal Instrument Works

Dr Sweat used traditional chiropractic adjustments and manual manipulations to treat patients for over 20 years. He then began using Atlas Orthogonal chiropractic techniques, specializing on correcting spinal issues with a precision adjustment instrument. Utilizing such an instrument eliminated many of the existing variables associated with hand contacts and thrust variation in treatment.

Atlas Orthogonal chiropractic therapy efficiently corrects issues which affect the normal range of motion of the vertebrae by producing a voluntary muscular contraction in comparison to manual manipulations which, by definition, take the joint, or several joints, beyond its present range of motion.

After several prototypes created throughout the years, the instrument nowadays is made from a metallic density, activated with a solenoid, or a magnetically influenced stylus which transfers to the conclusion in contact with all the skin’s surface. The pressure produced on the skin is as little as 3 pounds. The movement of the atlas bone has been verified through radiographic studies or X-rays.

Assorted Benefits of the Atlas Orthogonal

Recent studies demonstrate this phenomenon of leg duration inequality (LLI) might be engaged in spinal discomfort syndromes. The patient lies on their straight back, the healthcare professional’s contact with all the legs and feet is reserved to a minimum, while the variation in leg-length is measured. When the patient rests after each adjustment, this can be measured again, and also the chiropractor evaluates exactly what the change means.

The Atlas Orthogonal specialist contacts the soft-tissue overlying the factors of exit of the correct and left C 1 and C2 nerves and tissue compliance, irritation and tenderness. The four points are then rated from 0 to 3, with 3 being the most severe. There should be some instant improvement in the palpation after adjustment.

If more objectivity is needed, the more accepted method of algometry, or use of an epidermis pressure instrument, over the neck can elicit the same result. Instruments are being developed in the USA to supply goal measurement-based on tissue compliance.

Atlas Orthogonal chiropractic techniques ultimately can help relieve asthma, headaches, migraines, dizziness, arthritis, fibromyalgia, poor posture, trigeminal neuralgia, arm/leg pain, autism, allergies, neck/ back pain, carpel-tunnel, herniated disc, and stress, among others.

The scope of our information is limited to chiropractic and spinal injuries and conditions. To discuss options on the subject matter, please feel free to ask Dr. Jimenez or contact us at 915-850-0900Green-Call-Now-Button-24H-150x150.png

By Dr. Alex Jimenez

Additional Topics: Cervicogenic Headache and Chiropractic

Neck pain associated with whiplash-associated disorders resulting from an automobile accident are reportedly the most prevalent cause for discomfort along the cervical spine. The sheer force of an impact from a rear-end car crash or other traffic incident can cause injuries or aggravate a previously existing condition. While neck pain is commonly the result of damage to the complex structures of the neck, cervicogenic headaches may also result due to neck issues. Chiropractic care can help carefully restore the alignment of the cervical spine to relieve headaches and neck pain.

 

blog picture of cartoon paperboy big news

 

TRENDING TOPIC: EXTRA EXTRA: New PUSH 24/7�? Fitness Center

 

 

The Difference Between Atlas Orthogonal and Chiropractic

The Difference Between Atlas Orthogonal and Chiropractic

Chiropractic care is a non-conservative, alternative treatment option, preferred by many individuals who seek a more natural approach to treat their spinal complications. A chiropractor is a health care professional who focuses on the diagnosis, treatment and prevention of injuries and conditions associated with the musculoskeletal and nervous systems, with a greater emphasis on the spine.

The goal of chiropractic treatment is to reduce painful symptoms and improve the function of the structures of the body as well as educating patients to maintain their overall health and wellness via the proper practice of ergonomics, stretches and exercises.

Chiropractic care is generally categorized as complementary medicine, stimulating the individual’s body to heal itself naturally, without the need of drugs, medications and/or surgery. This practice focuses to improve the relationship between the spine and the nervous system.

A structural misalignment of the spine and/or a bio-mechanical derangement of the vertebral bones can affect the complex network of nerves found throughout the body. In these cases, the goal of chiropractic is to reduce the pressure on the neurological tissue in order to restore the structural integrity of the spine and improve the function of the nervous system, ultimately restoring the well-being of the patient. The primary treatment of a chiropractor is to re-establish the original mobility of the spine, alleviating irritation and inflammation on the structures surrounding the spine.

While a chiropractor, or doctor of chiropractic (DC), is qualified and experienced in the treatment of a variety of spinal conditions, other healthcare professionals within the field of chiropractic have special training in specific areas of the spine, utilizing different forms of treatment than the general chiropractor.

Atlas Orthogonal for the Cervical Spine

Atlas orthogonal is a specialized chiropractic technique which utilizes a precise adjusting instrument to treat complications along the cervical spine, or neck. This type of adjustment has been recognized for its precision and gentleness, in comparison with traditional chiropractic adjustments and manipulations, using only three ounces of pressure per procedure.

As a matter of fact, many patients find it hard to believe how such a light technique can provide them relief, at least until they begin to experience decreased pain and discomfort as well as improved function.

There are many different techniques to adjust the spine. The Atlas Orthogonal procedure is a system which helps balance the anatomical structure of the spine and its surrounding tissues, reducing neurological symptoms caused by spinal misalignment, or subluxation, without using manual manipulation. Atlas Orthogonal incorporates the use of a state of the art floor-based percussion adjusting instrument along with precision X-ray analysis, to properly diagnose, treat and prevent further complications within the cervical spine, particularly the atlas, the topmost vertebra of the spine in which the axis forms the joint that connects the skull and spine.

Most chiropractors, or doctors of chiropractic (DCs) use methods of adjusting where they feel the spine, followed by a manual manipulation or spinal adjustment performed by applying force along the affected structure until a “popping sound” is heard. With the Atlas Orthogonal chiropractic technique, the chiropractor uses specific X-rays to view the cervical spine and determine exactly where and how the vertebrae are misaligned or subluxated. The Atlas Orthogonal Percussion Instrument, utilized for the procedure, is then set with those specific vectors to accomplish the precise and gentle adjustment. The patient feels no force and hears no pops or cracks. Patients adjusted this way stay in adjustment longer than patients who receive treatment with other chiropractors. This means fewer adjustments and more cost-effective health care.

The Atlas Difference Summary

  • Gentle, effective approach ideal for children, elderly and osteoporotic patients
  • Modern equipment along with the latest techniques
  • Specific care that is specialized means fewer adjustments needed

About the Atlas Orthogonal Procedure

In conclusion, chiropractic care is a safe and effective treatment for both neck and back pain, as well as other spinal complications. According to the patient’s needs, some chiropractic adjustment techniques may be most beneficial to them than others. The Atlas Orthogonal chiropractic technique is a gentle and precise form of adjustment which can benefit many patients with cervical spine issues. Despite the variety of treatment and care options available in the chiropractic field, it’s ultimately important for people to treat their spinal complications to achieve overall health and wellness.

The scope of our information is limited to chiropractic and spinal injuries and conditions. To discuss options on the subject matter, please feel free to ask Dr. Jimenez or contact us at 915-850-0900Green-Call-Now-Button-24H-150x150.png

By Dr. Alex Jimenez

Additional Topics: Cervicogenic Headache and Chiropractic

Neck pain associated with whiplash-associated disorders resulting from an automobile accident are reportedly the most prevalent cause for discomfort along the cervical spine. The sheer force of an impact from a rear-end car crash or other traffic incident can cause injuries or aggravate a previously existing condition. While neck pain is commonly the result of damage to the complex structures of the neck, cervicogenic headaches may also result due to neck issues. Chiropractic care can help carefully restore the alignment of the cervical spine to relieve headaches and neck pain.

 

blog picture of cartoon paperboy big news

 

TRENDING TOPIC: EXTRA EXTRA: New PUSH 24/7�? Fitness Center