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Cervical Spine IDIOPATHIC NECK PAIN PowerPoint Presentation

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Published on : Dec 04, 2019 | Views : 1616 | Downloads : 4

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In the name of God Zeinab khodadadie
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Cervical Spine: IDIOPATHIC NECK PAIN The personal and societal burdens of mechanical neck pain of idiopathic origin are growing and likely reflect both contemporary occupational and lifestyle influences as well as the ageing population internationally. The annual prevalence of neck pain is variably reported as between 30% and 50% and is most common in the middle-aged population. Neck pain is characteristically a recurrent disorder which underscores the burden of neck pain and its effects on quality of life. Up to 85% of those who experience first episode neck pain will have a recurrence. Three distinct contemporary issues have been chosen for discussion in relation to mechanical neck pain towards more effective prevention and management: 1. patient profiling, 2. training, 3. cervical spine mobilization and manipulation.
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PROFILING PATIENTS WITH MECHANICAL NECK PAIN Patients with neck pain disorders are usually regarded within both medical diagnostic and biopsychosocial models. The diagnostic label of mechanical neck pain is used for disorders where: 1) current imaging techniques fail to identify a relevant lesion in the cervical structures, 2) onset is not related to a motor vehicle crash (for which the term whiplash associated disorder is used), 3) a cervical radiculopathy is not present, 4) there is no evidence that neck pain comes from a non-musculoskeletal cause. Over 80% of people with neck pain fall into the mechanical neck pain category.
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Patient presentations are variable. Biological, psychological and social features differ within and between domains and change at various time points within the course of a patient’s recovery. This suggests that an optimal management approach is based on gaining a comprehensive profile of the individual patient which is achieved through good communication and technical skills within a clinical reasoning process. Considerable research over the last two to three decades into mechanical neck pain across biological, psychological and social domains has revealed its many and varied features. This section illustrates some of this heterogeneity to support the position for multidimensional profiling of patients with mechanical neck pain as the basis for best practice management.
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Biological Perspectives Pain mechanisms are a primary consideration in diagnosis and management of patients with neck pain. They are variable between people and disorders. For instance, studies investigating primary and secondary mechanical hyperalgesia and thermal hyperalgesia have demonstrated that central sensitization (secondary hyperalgesia) may be present, but generally is a less dominant feature of mechanical neck pain when compared to whiplash- associated disorders. Nevertheless, there are specific instances which vary from such a generalization. For instance, Chua et al. demonstrated that a zygapophysial joint disorder was associated with primary hyperalgesia when it was a nociceptive source of a persistent neck pain disorder. Yet when the zygapophysial joint was a nociceptive source in patients with cervicogenic headache, it was also associated with secondary hyperalgesia and central sensitization. Pain mechanisms need to be identified in the individual patient as they influence treatment delivery.
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The greater the sensory disturbances, the less any intervention (manual therapy or exercise) should be pain provocative in nature to avoid potential symptom aggravation. There is now clear evidence of a reorganization of cervical motor control strategies include: altered coordination between deep and superficial neck muscles, a loss of muscles’ directional specificity and increased co-activation of neck flexor and extensor muscles during functional tasks. There are altered temporal features of muscle activity demonstrated by an increased latency between the onset of the deltoid muscle and onset of the neck muscles with rapid arm movement and delayed activation of the neck muscles during full body perturbations. People with neck pain display reduced strength and endurance at various contraction intensities and their neck muscles demonstrate increased fatigability.
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Patients may present with altered joint position and/or movement sense and control, impaired balance and altered oculomotor control particularly when there are complaints of light-headedness or unsteadiness in association with neck pain and/or headache. In summary, disturbances in sensorimotor function are a common feature of neck pain disorders but their presence and magnitude varies considerably between patients. This exemplifies the necessity for individual profiling when prescribing patient-specific exercise programmes.
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Psychological Perspectives Pain is an individual sensory and emotional experience. The adoption of the biopsychosocial model spurred an increase in research into psychological features. Whiplash-associated disorders have received the greatest attention, being compensable disorders with some unique psychological reactions (e.g. post-traumatic stress symptoms) identified. Here the focus is on findings in persons with idiopathic mechanical neck pain. Some level of anxiety and depression accompanies pain regardless of its source. Various psychological features have been identified in association with the neck pain experience, including: fear avoidance, somatization, catastrophization, poorer physical health, as have behavioural factors such as illness beliefs, coping skills and pain self-efficacy. A recent overview of systematic reviews on prognostic factors50 found that there was limited evidence of significant associations, and thus very low confidence in the risk, between several psychological and behavioural features and recovery from mechanical neck pain.
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This lack of evidence does not necessarily mean that psychological features have little role in the course of mechanical neck pain. Rather at this point in time there are too few studies or studies have produced conflicting results. it would seem that fear avoidance has some role in mechanical neck pain in the acute stage but may not have a substantial moderating effect on recovery for the majority of patients in the subacute or persistent stages of mechanical neck disorders. it seems that psychological responses are not a major feature in most patients with mechanical neck pain.
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Social Perspectives In considering social perspectives, extensive research has been undertaken into work-related neck pain. Generally, work absenteeism is not as great a problem for persons with neck disorders as it is in low back pain. Office or sedentary workers with mechanical neck pain in the main attend work (presenteeism) albeit their neck pain results in loss of productivity which is a problem in itself. Several social features have been identified as moderating work-related mechanical neck pain. They include low supervisor support, high job demands, low co-worker support, poor job satisfaction and low job control as well as work features (occupation type, manual labour, sustain work postures, awkward work postures) and poor physical work environment.
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It is artificial to consider physical, psychological or social features separately. true to the biopsychosocial model, the different elements of the model may interact and have the potential to positively or negatively influence neck pain.
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Patient Profiling in Clinical Practice An optimal management approach is based on gaining a comprehensive profile of the individual patient that appreciates the diversity and weights the biological, psychological and social aspects: We propose that from the biological perspective: it is necessary to understand physiological pain mechanisms and identify sources of peripheral nociception in the articular, neural and muscle systems that might benefit from physical therapies. it is necessary to fully profile the functional status of these systems in the upper quadrant through the assessment of posture, local and regional cervical and thoracic motion, nerve tissue motion and neck and axio-scapular muscle function. Clinical assessment of kinaesthetic sense, balance and oculomotor control is relevant especially in patients with symptoms of light-headedness or unsteadiness in association with their neck pain.
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The research into psychosocial features of patients with mechanical neck pain of idiopathic origin indicates that: in the majority of cases, psychological factors are likely to be a normal illness behaviour and often scores on psychological questionnaires are not high. This suggests that the weighting of this domain may be less than the biological domain for the majority of these patients. The information from psychological questionnaires should be used constructively to inform the therapeutic approach, rather than be regarded as a negative prognostic feature. many of the psychological features are normal but unhelpful reactions to pain (Yellow Flags). For instance, fear of movement is a normal and understandable response when neck pain is in the acute stage. It directs management to include assurance and education about pain and movement along with interventions to reduce the pain and increase motion. Fear usually declines as pain resolves. It would not be unusual for the patient to have some anxiety associated with a pain state. Good clinician–patient communication skills, empathy and education can assure the patient and help relieve the anxiety often associated with ‘the unknown’ about their pain or disorder.
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There will be some patients with neck pain who present with abnormally elevated scores on questionnaires for various psychological behaviours and beliefs or who demonstrate persisting abnormal illness behaviours, increasing the weighting of the psychological domain. The clinician should endeavour to understand why a person, for example is scoring highly on a catastrophization scale, and provide education and implement strategies that may assure or help relieve their distress within the management programme. If issues persist, however, referral to a clinician with appropriate advanced skills in behavioural modification or managing the patient in collaboration with an appropriately qualified practitioner such as a psychologist may be beneficial. It should be noted that scores from psychological questionnaires provide an indication of certain psychological symptoms, rather than a diagnosis. A diagnosis requires a clinical examination by a qualified practitioner such as a psychologist.
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In instances of occupationally related neck pain in particular, the social domain will assume a greater weighting: There is considerable evidence for the association between work-related physical exposures and neck pain. It is vital that any physical aspect of work that is a potential driver or moderator of the neck pain state is identified and rectified as much as is possible to gain long-term health benefits for the patient. Likewise, the clinician must gain an insight into the patient’s work environment with the knowledge that, for example, low supervisor support, most likely in association with other features, can moderate the course of recovery and outcome.
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The biopsychosocial model emphasizes the interactions between different domains and stresses the importance of the interaction between domains in a patient’s musculoskeletal pain state. There is no argument that mechanical neck pain is positioned well within the biopsychosocial model and no suggestion that patients present within only one domain of the model. Rather it is suggested that the weighting of the relative importance of biological, psychological and social domains varies between patients and that multidimensional profiling of patients is necessary to offer best practice patient-centred care.
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TRAINING Numerous studies support the prescription of exercise for the clinical management of mechanical neck pain. In particular, exercise aimed at improving neuromuscular control of the cervical spine and shoulder girdle has shown the strongest evidence of effect of all conservative therapies for mechanical neck pain, particularly when combined with manual therapy. The prescription of this form of exercise is justified by the numerous sensorimotor impairments that have been identified in mechanical neck pain including alterations in the timing and amplitude of activation of the neck and axio-scapular muscles during tasks of the cervical spine and upper limb, increased muscle fatigability, physical changes in muscle size, and fibre type composition. Ultimately, these alterations contribute to impaired motor output which include deficiencies in contractile strength and endurance, force steadiness and acuity of movement.
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Training for Pain Relief Similar changes in perceived neck pain and disability have been observed for various exercise programmes ranging from low-load training to improve neuromuscular control and posture, to high-load training to improve muscular strength and endurance. Thus various training approaches may be appropriate for the management of pain. However, patients may respond to different exercise protocols depending on the stage of their disorder and their level of pain and disability. For instance, gentle low-load exercise of the neck produces a superior immediate hypoalgesic effect compared to higher load exercise (Fig.1) and thus may be more appropriate in the initial stages of rehabilitation where the focus is on pain relief.
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Training to Restore Neuromuscular Function Therapeutic exercise of the neck has been shown to induce alterations in neck muscle behaviour in patients with mechanical neck pain including changes in the amplitude and specificity of neck muscle activity, as well as timing of muscle activity during postural perturbations. Changes in the physical structure of the neck muscles have also been demonstrated following neck exercise programmes including changes at the cellular level, as well as improvements in strength and endurance. Although these studies confirm that motor function can be modified by exercise in mechanical neck pain, it is relevant to compare the specific changes achieved by different training interventions. In contrast to the similar effects on clinical symptoms, neuromuscular changes in response to training are specific to the mode of exercise performed.
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For example, low-load coordination training, but not high-load strength training, is effective in increasing the activation of the deep cervical flexor muscles in mechanical neck pain, restoring the coordination between the deep and superficial flexors, enhancing the speed of activation of the deep muscles when challenged by a postural perturbation and improving the patient’s ability to maintain an upright posture of the cervical spine during prolonged sitting. In contrast, neck exercise programmes utilizing higher load endurance and strength protocols have shown superior gains in cervical muscle strength, endurance and resistance to fatigue compared to coordination training. These clinical studies confirm basic studies in exercise physiology which show that specific neuronal and muscle changes are dependent on the primary behavioural demand of training undertaken. Differences in the change in neck muscle behaviour induced by exercise may even occur when the biomechanical demands of two exercises are similar.
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A reduction in superficial neck flexor muscle activity during a task of craniocervical flexion was observed in patients with mechanical neck pain after weeks of low-load through-range craniocervical flexion (coordination) training, but not following isometric craniocervical flexion endurance training (despite biomechanical similarities between the two exercise protocols) or active movement training (despite an emphasis on correct movement patterns during training) (Fig. 2). greater gains in neck muscle endurance were acquired by the endurance training group compared to the other training groups
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Thus higher load resistance training can be introduced in the rehabilitation programme with the aim of inducing morphological adaptations in order to ameliorate endurance and strength of selected muscles and movements also known to be associated with mechanical neck pain.
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Transfer to Function A primary focus of rehabilitation is retraining capacity to perform daily functional activities that are often work-related. Importantly, optimizing muscle control when training a functional task requires specific instruction and facilitation. For example, enhanced activation of the longus colli/longus capitis and lumbar multifidus muscles has been shown in patients with mechanical neck pain during a therapist-facilitated postural correction exercise compared to independent sitting correction. What is unknown at this stage, however, is the degree to which specific changes in muscle control induced during formal exercise of muscle groups are transferred to the performance of functional tasks. there is some evidence that specific training of posture will improve neck muscle behaviour and reduce superficial neck flexor muscle activity during the craniocervical flexion task.
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Variability in Response to Training There is considerable variability in the extent of impairment in neuromuscular control of the cervical spine between individuals with mechanical neck pain. This variability is partially related to the magnitude of the patient’s neck pain intensity. For instance, augmented sternocleidomastoid and anterior scalene muscle activity during repetitive arm movements is greatest in patients reporting higher levels of pain and disability. Furthermore, higher levels of pain are associated with greater delays in the activation of the deep cervical flexors during postural perturbations and lower amplitude of activation during isometric craniocervical flexion. Recent work has shown that specific training of the deep cervical flexor muscles in patients with chronic neck pain reduces pain and increases the activation of these muscles, especially in patients with the least activation of their deep cervical flexors prior to training (Fig. 41-4).
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Thus although training is relevant to some degree for all patients with mechanical neck pain, the extent to which therapeutic exercise will benefit the patient from the point of view of pain will vary between individuals.
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Exercise Dosage to Address Recurrence Neck pain disorders are recurrent in nature. Logically, good neuromuscular control would contribute substantially to primary prevention and especially to secondary and tertiary prevention towards decreasing recurrence rate and slowing disease progression. Impaired neuromuscular control does not necessarily automatically resolve following relief of pain, which emphasizes the necessity for adequate rehabilitative exercise to restore normal muscle function. At present, there is little specific knowledge of what ‘dosage’ of exercise is required to restore ‘normal’ cervical neuromuscular control and research is required to address this issue. The outcome of training will likely be best when exercise is tailored to the patient’s presenting neuromuscular deficits.