Chronic neck pain, a common cause of disability, seems to be the result of several interacting mechanisms. In addition to degenerative and inflammatory changes and trauma, psychological and psychosocial factors are also involved. One common type of trauma associated with chronic neck pain is whiplash injury; this sometimes results in whiplash-associated disorder (WAD), a controversial condition with largely unknown pathogenetic mechanisms. We studied the prevalence of chronic neck pain of traumatic and non-traumatic origin and compared the prevalence of, sociodemographic data, self-perceived health, workload and chronic lowback pain in these groups. In a ready-made questionnaire (MONICA study), we added questions about cervical spine and low-back complaints. 6,000 (72%) completed a self-administered questionnaire. 43% reported neck pain: 48% of women and 38% of men. Women of working age had more neck pain than retired women, a phenomenon not seen in men. 19% of the studied population suffered from chronic neck pain and it was more frequent in women. A history of neck trauma was common in those with chronic neck pain. Those with a history of neck trauma perceived their health worse and were more often on sick-leave. About 50% of those with traumatic and non-traumatic chronic neck pain also had chronic low-back pain. We assessed the subjective and objective neuropsychological functioning in 42 patients with chronic neck pain, 21 with a whiplash trauma, and 21 without previous neck trauma. Despite cognitive complaints, the WAD patients had normal neuropsychological functioning, but the WAD group especially had deviant MMPI results—indicating impaired coping ability and somatization.WAD patients had no alterations in cerebral blood-flow pattern, as measured by rCBF-SPECT and SPM analysis, compared to healthy controls. This contrasts with the non-traumatic group with chronic neck pain, which showed marked blood-flow changes. The blood-flow changes in the non-traumatic group were similar to those described earlier in pain patients but— remarkably enough—were different from those in the WAD group. Chronic neck pain of whiplash and non-traumatic origin appears to be unique in some respects. A better understanding of the underlying pathological mechanisms is a prerequisite for prevention of the development of such chronic pain syndromes and for improvement of the treatment of patients with severe symptoms.

Pain from the musculoskeletal system is very common in the modern society. Chronic musculoskeletal pain syndromes causes not only individual suffering but also dysfunctions of movements and postural control, as large costs for the society. In spite of significant efforts, there is a shortage of knowledge on effective prevention, diagnoses and rehabilitation of different chronic musculoskeletal pain syndromes. The general aims of this thesis was to investigate the predictive value of physical, sociodemographic, and psychosocial-behavioural variables for pain reduction after multimodal rehabilitation in patients with chronic low back or neck pain, and to develop and evaluate tests for objective and quantitative evaluation of characteristic sensorimotor disturbances in chronic neck pain. Logistic regression models revealed that unchanged pain intensity could be predicted with good precision while reduced pain intensity after rehabilitation was poorly predicted by the baseline variables. Altered pain intensity in chronic low back pain was predicted by high pain intensity, low levels of pain severity and high affective distress, while reduced pain intensity for patients with chronic neck pain were predicted by high endurance, low age, high pain intensity, low need of being social along with optimistic attitudes on how the pain will interfere with daily life, and few vegetative symptoms. One of the conclusions was that objective measures of specific sensorimotor disturbances should improve the precision by which treatment-induced effects can be assessed and predicted. A study was designed to objectively and quantitatively evaluate a large numbers of different sensorimotor characteristics in a small group of patients with chronic neck pain of different aetiology (whiplash-related and insidious). Kinematic data was recorded during different motor tasks, involving cervical rotations, arm movements and standing. In comparison to a group of asymptomatic control subjects, patients with chronic neck pain was characterised by slower movements, poor balance, reduced cervical stability during perturbations, altered smoothness of movement (jerk index), and reduced movement precision (variable error and variability in range of motion). The sensorimotor variables velocity of arm movements and cervical stability, could correctly classified nearly 90% of the subjects as having chronic neck pain or being asymptomatic. There was a large diversity of sensorimotor disturbances among the individual patients. This was confirmed in a regression model that failed to separate the groups insidious neck pain (sensitivity 44%) and WAD (sensitivity 67%). By investigating associations between the different sensorimotor variables, close relations was found between the repositioning acuity and variability in range of motion, and between standing balance and cervical stability/ standing balance during perturbation. These two groups of variables were only weakly related to each other and to smoothness of movement and movement velocity. The results indicate that chronic neck pain is characterised by specific sensorimotor deficits, and that there are common pathophysiological mechanisms in chronic neck pain of different aetiology. However, the lack of associations between several sensorimotor disturbances indicates that different mechanisms are involved. The thesis indicates that objective sensorimotor tests should be used to improve the quality of functional assessments in chronic neck pain. Methods that objectively and quantitatively measure e.g. movement precision, balance and cervical stability are also needed in order to evaluate current treatment methods and to develop new rehabilitation programs for specific sensorimotor deficits.

Altered neuromuscular processing and motor output as both a risk and perpetuating factor for chronic neck pain is a relative new area of study. The cervical flexion relaxation response (FRR) is a reproducible and reliable marker of differences in neuromuscular function between neck pain patients and controls. Change in joint position sense (JPS) of upper limb joints has also been linked to chronic neck pain. Studies in this thesis sought to develop an experimental model in humans to investigate whether the FRR and JPS can be altered by fatigue and/or postural stress. Additionally a pilot study on the effect of three months of chiropractic treatment on the FRR was conducted. The studies revealed that muscular fatigue is a modulator of the FRR and may play a large role in spine stabilization. Minor postural alterations in the neck can impact joint position error at the elbow and 12 weeks of chiropractic care is a useful therapy to improve chronic and recurrent neck pain as well as improving the cervical FRR. / UOIT

Neck pain has the potential to result in altered afferent input to the central nervous system which may thereby result in altered sensorimotor integration and eventually further disability. One “at risk” population for neck pain may be university students, particularly given the growing use of laptop computers in the university setting. This thesis presents two pilot studies which aim to develop and assess instruments to use as screening tools for risk factors associated with neck pain. The first study explores the environment in which university students utilize their laptop computers and the relationship to known risk factors for neck pain. A new questionnaire, The Student Laptop Use and Neck Pain Risk Questionnaire (SLUNPRQ) was created to measure the presence of risk factors known to increase the risk of developing neck pain. This questionnaire was piloted for reliability using test- retest measures. Results indicated that the SLUNPRQ had good reliability based on Cohen’s Kappa scores. A modified questionnaire was developed based on questions with either low reliability or ambiguous answers and is ready for further testing. The second study sought to determine if dual somatosensory evoked potential (SEP) ratios changed with long term chiropractic care. This was part of the overall goal of finding neural markers that could identify those who are at risk for developing neck pain. This study sought to determine the feasibility of using dual SEPs to evaluate changes in neural markers of sensorimotor integration after 12 weeks of chiropractic care and demonstrated that dual SEPs shows potential as a marker to screen individuals at risk of neck pain as the SEP markers showed improvement after long term chiropractic care. / UOIT

Altered afferent input resulting from neck joint dysfunction has become a growing area of study. Cervical spine manipulation, specifically in individuals with subclinical neck pain (SNCP); induces neurological changes, suggesting it has a positive neuromodulatory effect on brain processing. The effects of manipulation on motor learning in individuals with SCNP have not been investigated until now. Studies in this thesis sought to develop and investigate a novel motor training task to be coupled with cervical spine manipulation to investigate its effects on individual’s ability to process new task information. The studies revealed significant changes in neural activity specific to the cerebellum and sensorimotor integration following a complex motor training task as compared to a simple repetitive task, suggesting that those specific regions are involved in processing of more complex motor skill learning tasks. This novel task was then coupled with manipulation which revealed significant activation increases in cortical and decreases in subcortical brain regions following manipulation. Regions specific to sensorimotor integration (SMI) showed increased activation in both the manipulation and passive head movement control groups, corroborating with the results from the first study. The use of a complex motor training task is a useful tool for determining intervention effects on neural processing in individuals with SCNP. / UOIT

published_or_final_version / Medical Sciences / Master / Master of Medical Sciences

Background: Neck pain is a major public health with great effects on both the individual and society. Cervical radiculopathy is a relatively common form of neck pain with neurological symptoms. Physical therapy is often the first treatment but there is paucity in literature reviews investigating the effects of physical therapy. Objective: To assess the effects of physical therapy for cervical radiculopathy. Methods: A literature search was conducted in PubMed, CINAHL, PEDro and Web of Science. A total of 12 RCT articles were included in the study. The articles were reviewed based on the aims of the study and the PEDro scale. Results: Eight studies of moderate quality and four high quality. Most studies used the same outcome measures. Most common interventions were traction and manual therapy. Outcomes were varied with some reporting positive effects and others no change. Treatment periods, number of sessions and follow-up varied. In most cases, the positive results wore off at follow-up and differences between groups less pronounced. Conclusions: The quality of RCTs investigating cervical radiculopathy is variable. There is limited evidence suggesting that physical therapy treatment can have a measurable and significant long-term effect on cervical radiculopathy. / Bakgrund: Nacksmärta är ett allvarligt folkhälsoproblem med stor effekt på både den enskilde och samhället. Cervikal radikulopati är en relativt vanlig form av nacksmärta med neurologiska symtom. Fysioterapi är ofta den första behandlingen för detta tillstånd men det är brist på litteraturstudier som undersöker fysioterapins effekter. Syfte: Att undersöka effekterna av fysioterapi för cervikal radikulopati. Metod: Litteratursökningar gjordes i PubMed, CINAHL, PEDro och Web of Science. Totalt inkluderades 12 RCT artiklar i studien. Artiklarna granskades utifrån studiens frågeställningar samt PEDro kvalitetsgranskningsmall. Resultat: Åtta studier var av måttlig kvalitet och fyra hög kvalitet. De flesta studier använde samma utfallsmått och alla uppmätte smärta, funktionshinder och funktion. De två vanligaste behandlingarna var traktion och manuell terapi. Resultaten av insatserna varierade då vissa rapporterade positiva effekter och andra ingen förändring. Behandlingsperioder, antal sessioner samt uppföljning varierade. I de flesta fall, så avtog de positiva resultaten vid uppföljning och skillnaden mellan grupperna blev mindre uppenbara. Konklusion: Denna litteraturöversikt påvisade att kvaliteten på de RCT studier som undersöker cervikal radikulopati varierar. Resultaten visar att det finns begränsad evidens som tyder på att fysioterapi kan ha en mätbar och betydande inverkan på cervikal radikulopati i längden.

Submitted in partial compliance with the requirements for the Master’s Degree in Technology: Chiropractic, Durban University of Technology, 2014. / Flexion distraction chiropractic technique (FDCT) is a commonly used manual therapy technique which is purported to address various clinical pain syndromes. However, it lacks the credibility of appropriate evidence-based guidelines. An analysis of the literature would be able to inform the development of guidelines. Objectives: The aim of this systematic review was to determine the evidence to support the use of FDCT in clinical practice. Data sources: A systematic review of PubMed and Summons was conducted, using the following search terms: chiropractic, flexion distraction, protocol and / or technique. Study selection: All electronic or paper, English articles, which possessed the required key indexing terms and represented randomised and non-randomised controlled study designs were included. Data extraction: Blinded review of the articles was conducted by three independent reviewers utilising the PEDro (for randomised controlled trials) and NOS for (non-randomised controlled trials). This allowed the methodological rigour of the article to be ranked. This ranking was compared to a critical appraisal of the article in order to achieve an overall decision with regards to the contribution of the article to the level of evidence for FDCT. Data synthesis: 18 review outcomes were aggregated around four clinical categories; two articles each on neck pain, chronic pelvic pain, and physiological outcomes and the remaining twelve on low back pain. There was agreement that the evidence for pelvic pain and physiological function was limited to no evidence and limited respectively. Conflicting evidence existed for neck and low back pain (single and multimodal treatment) with limited and moderate evidence respectively. Conclusion: FDCT is clinically advocated for many conditions. The evidence provided in this review indicates that practitioners should be guarded in their use of FDCT, as the evidence to its widespread use is limited to only those conditions noted in this review. Therefore, further high quality and rigorous studies are required to develop appropriate treatment guidelines for use by practitioners to adequately provide evidence based care in clinical practice.

Background: Headache is common in the elderly. Cervical degenerative changes are universal with ageing and cervicogenic headache is proposed (albeit without evidence) as a frequent cause of headache in this age group. Previous research identified a pattern of cervical musculoskeletal impairment which differentiated cervicogenic headache from other frequent headaches but this study was undertaken on younger/middle aged individuals. The value of this diagnostic pattern could be questioned for an older population with concomitant age related changes in the musculoskeletal system. The first and foremost aim of this research was to determine if cervical musculoskeletal impairment was specific to headaches classifiable as cervicogenic or was more generic to headache in elders. Participants with headache were sub-grouped on the basis of the pattern of cervical musculoskeletal impairment and the relationship between this grouping and headache classification was investigated. The presence of sensory hypersensitivity and psychological distress are features of headache that can provide information on the underlying mechanisms and provide management directives for headache. There is little knowledge of whether or not these features are influenced by a factor of age. Thus the second and third aims of this research were to investigate sensory features and psychological and quality of life features in the elderly with headache. Methods: One hundred and eighteen subjects, aged 60 to 75 years with recurrent headache and 44 controls were studied. Ninety-three reported a single headache and 25, two or more headache types. All subjects completed the Neck Disability Index (NDI), Geriatric Depression Scale-short form (GDS-S) and SF-36 questionnaires. Subjects with headache also completed a headache questionnaire and the Survey of Pain Attitudes (SOPA-35). Neck function measures included range of motion, manual examination of cervical segments, cranio-cervical flexor muscle function, joint position sense, cervical muscle strength, cross-sectional area of selected cervical extensors and posture. Sensory measures included pressure pain thresholds (PPTs) and thermal pain thresholds (TPTs). PPTs were measured over the forehead, upper neck and at a remote site (tibialis anterior). TPTs were measured over the upper neck. Results: Cluster analysis, based on the three musculoskeletal variables aligned previously with cervicogenic headache, divided headache subjects into two groups; cluster 1 (n = 57), cluster 2 (n = 50). There was significantly reduced cervical extension, axial rotation, rotation in neck flexion and lateral flexion in the headache clusters than the control group, and in the frequency of symptomatic joint dysfunction (C0-1 – C7-T1) (all p < 0.05). Subjects in cluster 1 had significantly reduced range of cervical extension and axial rotation and frequency of symptomatic joint dysfunction (C1-2 and C7-T1) compared to those in cluster 2 and controls (all p < 0.05). More subjects in cluster 1 had headaches ≥ 15 days per month and histories of head/neck trauma (both p < 0.05). Most cervicogenic headaches were grouped in cluster 1, but musculoskeletal dysfunction was also found in headaches classifiable as migraine or tension-type headache. The analysis of subjects with single headaches revealed no significant differences between the headache groups (migraine, tension-type, cervicogenic and unclassifiable headaches) and controls in pressure and cold pain thresholds (all p > 0.05). Heat pain thresholds were significantly lower in the headache groups compared to controls (all p < 0.01) but there were no differences between headache types (all p > 0.05). There were no strong relationships between any headache variable and pain thresholds. Elders with headache scored lower on most SF-36 domains, higher on the GDS-S (p < 0.05) and comparably on the SOPA-35 (p > 0.05) compared to the control group. The GDS score was below the threshold value for depression. Differences in these measures were not dependent on the headache types but rather, headache frequency. Subjects with headaches ≥ 15 days/month scored lowest on SF-36 domains and highest on GDS-S questionnaire compared to those with headache < 15 days/month and controls (all p < 0.05). The mean NDI score in the subjects with headache indicated the presence of mild to moderate neck pain and disability. No strong relationships were found between well-being and headache frequency, intensity and length of headache history. The NDI score had the greatest influence on physical well-being and GDS-S score on mental well-being (p < 0.001). Conclusions: Several aspects of cervical musculoskeletal function, heat thresholds, general well being and quality of life were altered in elders with headache. Neck dysfunction was not uniquely confined to cervicogenic headache but was a generic feature of headache in the elderly. No generalized changes in pain sensitivity were present in elders with headache. Headache had a significant impact on elders’ quality of life but was not associated with depression. Neck pain was an important factor influencing function and well-being. Conservative management such as physiotherapy may be a safe and appropriate option for elders with headache, given its frequent association with cervical musculoskeletal impairment. Further research is required for a better understanding of the neck’s role in elders’ headache.

Thesis (M.CM)--Hong Kong Baptist University, 2006. / Dissertation submitted to the School of Chinese Medicine. Includes bibliographical references (leaves 29-31).