Relationship between subjective neck disorders and cervical spine mobility and motion-related pain in male machine operators

Decreased Muscle Strength and Mobility of the Neck in Patients With Rheumatoid Arthritis and Atlantoaxial Disorders

OBJECTIVE

To compare neck muscle strength and mobility of the cervical spine in rheumatoid arthritis (RA) patients with and without atlantoaxial (AA) disorders (anterior atlantoaxial subluxation [AAS], AA impaction).

DESIGN

Clinical cross-sectional study.

SETTING

Outpatient rheumatology and rehabilitation clinics in a Finnish hospital.

PARTICIPANTS

Patients with RA (N=124; mean age +/- standard deviation, 62+/-12y [corrected]) on a waiting list for orthopedic surgery. Thirty (24%) patients presented with AA disorders (16 with anterior AAS, 8 with AA impaction, 6 with a combination of anterior AAS and AA impaction).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Neck function was measured by isometric neck strength and mobility tests, neck pain by a visual analog scale, erosion of the hands and feet by radiography, and the patients' function by the Health Assessment Questionnaire (HAQ).

RESULTS

Maximal neck muscle strength against flexion, extension, and rotation was lower in patients with AA disorders compared with the other patients in both women (P=.012) and men (P=.017). Mobility was lowest in the AA impaction group in all measured directions (P<.001). Peripheral erosive disease was more frequent in the group with AA disorders. They also had longer disease duration and were more disabled (HAQ) than the other patients.

CONCLUSIONS

Neck muscle strength is significantly decreased in patients with AA disorders. Mobility of the cervical spine is most limited in patients with AA impaction, but can be normal in cases with solitary anterior AAS.

Correlation among physical impairments, pain, disability, and patient satisfaction in patients with chronic neck pain

OBJECTIVE

To investigate the correlations among pain, physical impairments, disability, and patient satisfaction in patients with chronic neck pain.

DESIGN

A longitudinal cohort study with 6-month follow-up.

SETTING

Institutional practice.

PARTICIPANTS

Subjects (N=218) with chronic neck pain.

INTERVENTIONS

Subjects were treated with different physiotherapy modalities.

MAIN OUTCOME MEASURES

Data were obtained for self-reported disability, verbal numeric pain scale, patient satisfaction, and 2 measures of physical impairments during the initial visit, at 6 weeks, and finally at 6 months.

RESULTS

The correlation among 4 sets of measurements varied. Moderate correlation was noted between disability and patient satisfaction ( r range, .50-.65), and between disability and pain ( r range, .55-.63). A fair relationship was found between pain and patient satisfaction ( r range, .43-.48), but only weak relationships were found between physical impairments and pain ( r range, -.08 to -.25). The correlations tended to increase in the follow-up assessments.

CONCLUSIONS

No strong correlations were found among disability, patient satisfaction, pain, and physical impairments although the correlations tended to increase in the follow-up assessments. The findings support the suggestion that clinicians should address as many relevant aspects of a presenting clinical entity as possible in the management of chronic neck pain.

Measurement of cervical range of motion pattern during cyclic neck movement by an ultrasound-based motion system

Goniometers and radiographic imaging have been used to measure active or passive cervical range of motion (ROM) in asymptomatic adults. However, the ultrasound-based coordinate measuring system (CMS) can measure continuous neck motion in three dimensions. The aims of this investigation are to evaluate the reliability and validity of ultrasound-based CMS (Zebris, CMS 70P), and to compare the cervical ROM patterns of asymptomatic young and middle-aged adults during continuous neck motions in the three cardinal planes. The ROM reciprocal ratio was defined as the ratio of the ROM from neutral position in one direction versus that in the opposite direction at the same cardinal plane. This study demonstrated the high test-retest reliability and validity of CMS during cervical motion in Chinese participants. Middle-aged adults exhibit reduced ROM ratios in the sagittal and frontal planes. The advantages and limitations of the CMS measurement tool and the potential future applications are documented. The measurement of neck motion pattern by ultrasound-based CMS may provide information on the management of neck dysfunction during functional movements.

Do changes within a manual therapy treatment session predict between-session changes for patients with cervical spine pain?

Physiotherapists often use within-session changes to provide a guide for refining treatment application. This study tested the validity of within-session changes as predictors of between-session changes for patients with neck pain receiving manual therapy treatment. A total of 70 pairs of treatments from 29 patients with sub-acute non-specific neck pain receiving manual therapy were assessed to determine the relationship between within-session and between-session changes in range of motion (ROM), pain intensity, and centralisation. Measurements were taken of ROM of the more limited direction on each axis of flexion, extension, lateral-flexion and rotation, and pain (intensity and location) before and after treatment. The same measurements were repeated before the following treatment. Regression analysis demonstrated that within-session change accounted for 26% to 48% of the variability in between-session change for ROM and six per cent for pain intensity. The proportion of the within-session change for ROM maintained between sessions ranged from 42% to 63% (95% CI 25% to 88%). The odds ratios for within-session improved/not improved categorisation to predict between-session category for ROM ranged from 2.5 (95% CI 0.6 to 4.3) to 21.3 (95% CI 10.1 to 96.1), for pain intensity 4.5 (95% CI 1.2 to 14.4) and for pain centralisation 9.2 (95% CI 2.2 to 38.7) indicating greater likelihood of between-session improvement after within-session improvement. The between-session results for most patients (71% to 83%) could be classified correctly by their within-session category. The results support the use of within-session changes in ROM, centralisation, and possibly pain intensity as predictors of between-session changes for musculoskeletal disorders of the cervical spine.

A specific exercise program and modification of postural alignment for treatment of cervicogenic headache: a case report

STUDY DESIGN

Case report.

OBJECTIVE

To describe an intervention approach consisting of a specific active-exercise program and modification of postural alignment for an individual with cervicogenic headache.

BACKGROUND

The patient was a 46-year-old male with a 7-year history of cervicogenic headache. He reported constant symptoms with an average intensity of 5/10 on a visual analogue scale where 0 indicated no pain and 10 the worst pain imaginable. Average pain intensity in the week prior to the initial evaluation was 3/10 secondary to trigger point injections. The patient's headache symptoms worsened with activities that involved use of his arms and prolonged sitting.

METHODS AND MEASURES

The patient was treated 7 times over a 3-month period. Impairments of alignment, muscle function, and movement of the cervical, scapulothoracic, and lumbar regions were identified. Outcome measurements included headache frequency, intensity, and the Neck Disability Index (NDI) questionnaire. Intervention included modification of alignment and movement during active cervical and upper extremity movements. The patient also received functional instructions focused on diminishing the effect of the weight of the upper extremities on the cervical spine.

RESULTS

The patient reported a decrease in headache frequency and intensity (1 headache in 3 weeks, intensity 1/10) and a decrease in his NDI score from 31 (severe disability) to 11 (mild disability). The patient also demonstrated improvement in upper cervical joint mobility, cervical range of motion, scapular alignment, and scapulothoracic muscle strength.

CONCLUSION

Interventions that included modification of alignment in the cervical, scapulothoracic, and lumbar region, along with instruction in a specific active-exercise program to address movement impairments in these 3 regions, appeared to have been successful in relieving headaches and improving function in this patient.

An investigation into the validity of cervical spine motion palpation using subjects with congenital block vertebrae as a 'gold standard'

Background

Although the effectiveness of manipulative therapy for treating back and neck pain has been demonstrated, the validity of many of the procedures used to detect joint dysfunction has not been confirmed. Practitioners of manual medicine frequently employ motion palpation as a diagnostic tool, despite conflicting evidence regarding its utility and reliability. The introduction of various spinal models with artificially introduced 'fixations' as an attempt to introduce a 'gold standard' has met with frustration and frequent mechanical failure. Because direct comparison against a 'gold standard' allows the validity, specificity and sensitivity of a test to be calculated, the identification of a realistic 'gold standard' against which motion palpation can be evaluated is essential. The objective of this study was to introduce a new, realistic, 'gold standard', the congenital block vertebra (CBV) to assess the validity of motion palpation in detecting a true fixation.

Methods

Twenty fourth year chiropractic students examined the cervical spines of three subjects with single level congenital block vertebrae, using two commonly employed motion palpation tests. The examiners, who were blinded to the presence of congenital block vertebrae, were asked to identify the most hypomobile segment(s). The congenital block segments included two subjects with fusion at the C2–3 level and one with fusion at C5-6. Exclusion criteria included subjects who were frankly symptomatic, had moderate or severe degenerative changes in their cervical spines, or displayed signs of cervical instability. Spinal levels were marked on the subject's skin overlying the facet joints from C1 to C7 bilaterally and the motion segments were then marked alphabetically with 'A' corresponding to C1-2.

Kappa coefficients (K) were calculated to determine the validity of motion palpation to detect the congenitally fused segments as the 'most hypomobile' segments. Sensitivity and specificity of the diagnostic procedure were also calculated.

Results

Kappa coefficients (K) showed substantial overall agreement for identification of the segment of greatest hypomobility (K = 0.65), with substantial (K = 0.76) and moderate (K = 0.46) agreement for hypomobility at C2-3 and C5-6 respectively. Sensitivity ranged from 55% at the C5-6 CBV to 78% at the C2-3 level. Specificity of the procedure was high (91 – 98%).

Conclusion

This study indicates that relatively inexperienced examiners are capable of correctly identifying inter-segmental fixations (CBV) in the cervical spine using 2 commonly employed motion palpation tests. The use of a 'gold standard' (CBV) in this study and the substantial agreement achieved lends support to the validity of motion palpation in detecting major spinal fixations in the cervical spine.

Cervical range of motion associations with subclinical neck pain

STUDY DESIGN

Cross-sectional study.

OBJECTIVE

To investigate associations between subclinical neck pain/discomfort, and range of motion and physical dimensions of the cervicothoracic spine.

SUMMARY OF BACKGROUND DATA

Despite the high prevalence of neck problems, few studies are available indicating any physical associations with the development of neck pain, or information regarding early signs of pathology from neck pain for subjects not in treatment.

METHODS

Forty healthy volunteers, between 19 and 42 years of age (mean age 28 years), were recruited. The dimensions of the cervicothoracic spine measured were as follows: spinal posture, active cervical range of motion, and segment length of the neck. All measurements were taken twice from each subject by different testers, on the same occasion. Cervical muscle endurance was measured by a modified Biering-Sørensen Test. Finally, subjects were questioned about any recurrent neck pain/discomfort.

RESULTS

Fourteen subjects reported experiencing low-level neck pain/discomfort on a recurrent basis. Neck muscle endurance time (F1,38 = 6.75, P = 0.01) and left rotation end-of-range (F1,38 = 4.56, P = 0.04) were found to be significantly lower for subjects with neck pain. Extension end-of-range showed a group-specific change at retest, increasing for subjects without pain, but decreasing for those with neck pain (F1,38 = 4.67, P = 0.04). This same group had a greater range of retraction than the asymptomatic group (F1,38 = 4.56, P = 0.04). Subjects overall, irrespective of pain classification, demonstrated greater left rotation than right rotation (F1,38 = 4.34, P = 0.04) and also showed reduced side flexion on the left (F1,38 = 5.10, P = 0.03) and right (F1,38 = 5.27, P = 0.03) with repeated measurement.

CONCLUSIONS

Between-groups differences were observed as lower neck muscle endurance time, reduced left rotation, relatively reduced extension at second test, but greater range of retraction, when the subclinical and normal groups were compared. These data suggest that there are early range changes associated with the development of neck pain.

Zebris versus Myrin: a comparative study between a three-dimensional ultrasound movement analysis and an inclinometer/compass method: intradevice reliability, concurrent validity, intertester comparison, intratester reliability, and intraindividual variability

STUDY DESIGN

Experimental study.

OBJECTIVES

To compare two devices for measuring cervical range of motion, a three-dimensional ultrasound motion device (Zebris) and a gravity-reference goniometer (Myrin).

SUMMARY OF BACKGROUND DATA

Assessment of cervical range of motion is used to evaluate the effect of different treatments, determine impairment, and ascertain the relationship between neck disorders and cervical spine mobility.

METHODS

Sixty "neck-healthy" volunteers (25 men, 35 women; mean age 38 years, range 22-58 years) performed active maximal movements in flexion-extension, rotation, and lateral flexion. Maximal cervical range of motion was recorded simultaneously with the Zebris and Myrin devices. Intradevice reliability, concurrent validity, intertester comparison, intratester reliability, and intraindividual variability were computed.

RESULTS

Our study showed good agreement of full-cycle cervical range of motion measurement between devices, testers, and the test and retest (intraclass correlation [ICC] was >0.90 for intradevice reliability, >0.93 for concurrent validity, and >0.92 for intratester reliability). Method error, assessed with the within-subject coefficient of variation for 95% of the measurements, was 5.4% to 11.1% for intradevice reliability, 4.4% to 7.6% for concurrent validity, 3.6% to 7.6% for intratester reliability, and 5.3% to 9.9% for individual variability. Individual variability did not increase with an increased cervical range of motion.

CONCLUSION

Both devices are reliable and showed good agreement. We conclude that the two techniques can be used interchangeably. Our study supports the continued use of the Myrin-a gravity-reference goniometer in routine clinical orthopedic work. The more sophisticated three-dimensional method adds information and allows evaluation of combined motion in two and three dimensions and is suitable for research.

3D kinematic analysis and clinical evaluation of neck movements in patients with whiplash injury

In recent decades whiplash injuries, being a major reason for compensation claims, have become increasingly important in forensic medicine. In view of this, a reliable diagnostic method of assessing cervical range of motion (ROM) is needed. The aim of the present study was to evaluate neck function with a 3D kinematic method compared with clinical evaluation in whiplash injury. Seventy consecutive patients (M/F = 18/52) with a history of whiplash injury (WH) and 46 healthy volunteers (M/F = 24/22), mean age, respectively 33 +/- 9 and 28 +/- 6 years (mean+/-SD) entered the study. Patients suffered from neck pain and/or unilateral headache. A computerized kinematic analysis of the ROM (Elite system) using passive markers and two infrared TV cameras was used. Clinical evaluation of active ROM was also performed both in patients and in 61 controls (M/F = 23/38; mean age 47 +/- 18 years). Thirty out of 70 patients were tested at the time of their first consultation (T0) and 6 months later (T6), and 12 were also followed up after a year (T12). All neck movements, except extension, were significantly reduced in WH subjects compared with controls, in particular lateral bending. Comparing ROM at T0, T6 and T12, no significant differences were found. A global index of motion (GIM), obtained by calculating the sum of ROM in absolute value for all the movements acquired, was significantly reduced in WH compared with control subjects. The interobserver reliability of the clinical evaluation was globally acceptable. On the basis of the clinical evaluation, a significantly reduced ROM was found in all movements in WH subjects compared with an age-matched population. Computing the number of impaired cervical movements (ICMs), a significantly higher number was observed in WH patients than in controls, showing a decreasing trend at T6 and T12, with a significant improvement at T6 vs. T0. The computerized study of neck ROM may constitute a useful tool in the evaluation of WH at baseline and follow-up.

Immediate effects of dry needling and acupuncture at distant points in chronic neck pain: results of a randomized, double-blind, sham-controlled crossover trial

To evaluate immediate effects of two different modes of acupuncture on motion-related pain and cervical spine mobility in chronic neck pain patients compared to a sham procedure. Thirty-six patients with chronic neck pain and limited cervical spine mobility participated in a prospective, randomized, double-blind, sham-controlled crossover trial. Every patient was treated once with needle acupuncture at distant points, dry needling (DN) of local myofascial trigger points and sham laser acupuncture (Sham). Outcome measures were motion-related pain intensity (visual analogue scale, 0-100 mm) and range of motion (ROM). In addition, patients scored changes of general complaints using an 11-point verbal rating scale. Patients were assessed immediately before and after each treatment by an independent (blinded) investigator. Multivariate analysis was used to assess the effects of true acupuncture and needle site independently. For motion-related pain, use of acupuncture at non-local points reduced pain scores by about a third (11.2 mm; 95% CI 5.7, 16.7; P = 0.00006) compared to DN and sham. DN led to an estimated reduction in pain of 1.0 mm (95% CI -4.5, 6.5; P = 0.7). Use of DN slightly improved ROM by 1.7 degrees (95% CI 0.2, 3.2; P = 0.032) with use of non-local points improving ROM by an additional 1.9 degrees (95% CI 0.3, 3.4; P = 0.016). For patient assessment of change, non-local acupuncture was significantly superior both to Sham (1.7 points; 95% CI 1.0, 2.5; P = 0.0001) and DN (1.5 points; 95% CI 0.4, 2.6; P = 0.008) but there was no difference between DN and Sham (0.1 point; 95% CI -1.0, 1.2; P = 0.8). Acupuncture is superior to Sham in improving motion-related pain and ROM following a single session of treatment in chronic neck pain patients. Acupuncture at distant points improves ROM more than DN; DN was ineffective for motion-related pain.

Randomised trial of acupuncture compared with conventional massage and "sham" laser acupuncture for treatment of chronic neck pain

OBJECTIVES

To compare the efficacy of acupuncture and conventional massage for the treatment of chronic neck pain.

DESIGN

Prospective, randomised, placebo controlled trial.

SETTING

Three outpatient departments in Germany.

PARTICIPANTS

177 patients aged 18-85 years with chronic neck pain.

INTERVENTIONS

Patients were randomly allocated to five treatments over three weeks with acupuncture (56), massage (60), or "sham" laser acupuncture (61).

PRIMARY OUTCOME MEASURE

maximum pain related to motion (visual analogue scale) irrespective of direction of movement one week after treatment.

SECONDARY OUTCOME MEASURES

range of motion (3D ultrasound real time motion analyser), pain related to movement in six directions (visual analogue scale), pressure pain threshold (pressure algometer), changes of spontaneous pain, motion related pain, global complaints (seven point scale), and quality of life (SF-36). Assessments were performed before, during, and one week and three months after treatment. Patients' beliefs in treatment were assessed.

RESULTS

One week after five treatments the acupuncture group showed a significantly greater improvement in motion related pain compared with massage (difference 24.22 (95% confidence interval 16.5 to 31.9), P=0.0052) but not compared with sham laser (17.28 (10.0 to 24.6), P=0.327). Differences between acupuncture and massage or sham laser were greater in the subgroup who had had pain for longer than five years (n=75) and in patients with myofascial pain syndrome (n=129). The acupuncture group had the best results in most secondary outcome measures. There were no differences in patients' beliefs in treatment.

CONCLUSIONS

Acupuncture is an effective short term treatment for patients with chronic neck pain, but there is only limited evidence for long term effects after five treatments.

Noninvasive three-dimensional analysis of cervical spine motion in normal subjects in relation to age and sex. An experimental examination

STUDY DESIGN

Experimental examination in vivo.

OBJECTIVES

To determine the precision of the ultrasound-based Coordinate Measuring System (CMS 50; Zebris Medizintechnik GmbH, D-88316, Isny, Germany) and then to establish a reference range for the active range of motion of the cervical spine in normal test subjects grouped according to age and sex.

SUMMARY OF BACKGROUND DATA

Many different devices such as inclinometers, goniometers, potentiometers, computer-aided devices, and radiographic procedures have been developed to examine the range of motion of the cervical spine. All of them have more or less inherent limitations.

METHODS

To assess the precision of this examination method, preliminary experiments were performed including intraobserver retest and two-observer repeatability, intraindividual variability, a daily profile, and a comparison between active and passive motions. In the subsequent main experiment 157 persons (86 women and 71 men) were examined during active motion. The sex groups were further subdivided into age groups of 10 years each. A comparison of weight and athletic activity was also performed.

RESULTS

The range of motion decreased with increasing age, increasing body weight, and decreasing athletic activity. The rotation in the upper cervical spine increases with age to compensate for the reduced range of motion in the lower levels. Women showed significantly better mobility than men of the same age, only above the age of 70.

CONCLUSIONS

The CMS 50 device provides precise reproducible measurements of the active range of motion of the cervical spine in all three planes. Criteria such as age, sex, body weight, and athletic activity influence the range of motion of the cervical spine.

Meta-analysis of normative cervical motion

STUDY DESIGN

Meta-analysis of normative cervical range of motion literature performed by applying summary statistics to range of motion and reliability values reported among studies.

OBJECTIVES

To identify reliable and valid methods for measuring active and passive cervical range of motion and to estimate normative values.

SUMMARY OF BACKGROUND DATA

Range of motion studies use a variety of measuring instruments and statistical analyses, making it difficult to select the most suitable instruments, procedures, and normative values for clinical application. Reviews of the literature, being limited in scope, have not quantitatively synthesized the literature.

METHODS

Range of motion and reliability data were grouped by technology and types of motion, then summarized by deriving means and variabilities. Clinical validity was assessed by examining discrepancies, variabilities, and correlations. Change in range of motion as a function of age was determined by comparing range of motion ratios (fourth:third and seventh:third decades).

RESULTS

Nine technologies were identified. Overall, passive motion was greater than active motion, and range of motion decreased as age increased, with women exhibiting greater range of motion than men. Variations within each technology were as large as or larger than those between technologies, indicating that clinical procedures are as important as the accuracy and precision of the technology itself. Reliability has not been adequately tested for the majority of technologies.

CONCLUSIONS

Clinical procedures appear to be as important as accuracy and precision in determining the reported range of motion values. Further research is needed to establish a gold standard for normative values and to identify an instrument that is reliable for all motions.

The ability to reproduce the neutral zero position of the head

OBJECTIVE

To determine how precisely asymptomatic subjects can reproduce a neutral zero position of the head.

STUDY DESIGN

Repeated measures of the active cervical neutral zero position.

SETTING

Institute of Medical Biology (Center of Biomechanics) at Odense University.

PARTICIPANTS

Thirty-eight asymptomatic students from the University of Odense, male/female ratio 20:18 and mean age 24.3 years (range, 20 to 30 years).

INTERVENTION

Measurements of the location of the neutral zero head position by use of the electrogoniometer CA-6000 Spine Motion Analyzer. Each subject's neutral zero position with eyes closed was measured 3 times. The device gives the localization of the neutral zero as coordinates in 3 dimensions (x, v, z) corresponding to the 3 motion planes.

RESULTS

The mean difference from neutral zero in 3 motion planes was found to be 2.7 degrees in the sagittal plane, 1.0 degree in the horizontal plane, and 0.65 degree in the frontal plane.

CONCLUSION

We found that young adult asymptomatic subjects are very good at reproducing the neutral zero position of the head. This suggests the existence of some advanced neurologic control mechanisms.