Whiplash, headache, and neck pain : research-based directions for physical therapies

240 Pages·2008·6.769 MB·English

by  Gwendolen A Jull, et al

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First published 2008
ISBN: 978-0-443-10047-5
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Preface
Research into cervical spine disorders played consequence, neck pain disorders can present
second fi ddle to low-back pain for a large with some unique problems. Fortunately
part of the 20th century. However, in the last the era of trying to force the application of
two decades in particular, there has been a knowledge from the low back to neck pain
rapid increase in interest and research into is gradually disappearing.
cervical musculoskeletal disorders, which is The diagnosis and management of cervical
well warranted. musculoskeletal disorders are assuming new
Neck pain is beginning to rival low-back directions. The focus on pathoanatomical
pain in its frequency and the economic and diagnoses is gradually shifting towards
social costs for neck pain have increased a more processes or pathophysiological
leading into the 21st century. The seeming approach in the recognition that in the
increase in the incidence of neck pain may be majority of neck disorders a defi nitive
related to many factors, including advances pathoanatomical cause may not be able to be
in technologies in the workplace and thus readily identifi ed in up to 80% of neck pain
the changing nature of work, the increased patients. This shift in focus has also been
use of motor vehicles throughout the world, assisted by major advances in knowledge
and the rapid rise of information technology and technology. There have been dramatic
and computer use which occupies many advances in knowledge of pain mechanisms
hours in sedentary, sustained postures. over recent decades. Technologies are
Neck pain is now rapidly developing assisting in bridging the gap between animal
its own body of science. There are many research and pain presentations in humans.
examples in the literature of the 1980s and Advances in electromyographic techniques
1990s where knowledge gained for low-back have allowed a more comprehensive
pain was merely extrapolated and applied exploration of the cervical muscle system
to cervical musculoskeletal disorders in and motor control. There is more to explore
both diagnostics and management. This was and learn in all fi elds before we will fully
clearly inadequate, as more contemporary understand neck pain. Nevertheless the
research is revealing. The cervical spine rapid advances of the past two decades have
is anatomically and biomechanically very laid a foundation for improvements in the
different from the lumbar spine, in accordance understanding and management of cervical
with the different functional roles of these disorders which will benefi t the neck pain
regions. While the muscle systems in the two patient and clinician alike.
regions have some similarities, they also have This text emanates from the research
vast differences, as could be expected with and clinical interests of the authors over
their different functions. In addition, cervical the past 10 years in particular. Collectively,
structures have unique neurophysiological we have particular interests in whiplash-
connections to the vestibular and oculomotor associated disorders, cervicogenic headache,
systems. The structures of the cervical cervicobrachial, and idiopathic neck pain.
spine are vulnerable to trauma, as occurs, As physiotherapists, we have researched
for example, in a motor vehicle crash in towards developing enhanced clinical
ways not experienced in the low back. The diagnoses of neck disorders as well as
psychological reactions that can accompany developing the foundations for specifi c
neck pain are often quite different from rehabilitation and prevention strategies
those found with chronic low-back pain. In for neck pain. The research has developed
viii Preface
from an applied clinical perspective. Our This text presents the applied sciences,
philosophy is that if we understand, identify, assessment, and rehabilitation protocols for
and quantify the abnormal features involved the management of cervical disorders. In
in neck disorders from a broad multisystems writing the text, we have used the available
pathophysiological perspective, this will international body of knowledge. However
lay the foundation for better differential the text has principally been developed and
diagnosis and rehabilitation. It is our guided by the outcomes of our research and
contention that understanding the under- its translation to clinical practice. Research
lying processes of cervical disorders as is an ongoing process and we look forward
well as their development over time will to developments in the fi eld over the next
assist in developing clinically meaningful 10 years.
subcategories of neck disorders and most GJ
importantly will direct the development MS
of specifi c and relevant rehabilitation and DF
prevention strategies. We have developed JT
and tested new rehabilitation strategies and
for neck disorders and this process, like all S O’L
research, is ongoing. 2008
Foreword
Whiplash, Headache, and Neck Pain is a it must be said that all authors contributing
unique text presenting the examination, to this text have developed and carried out
interpretation and the conservative their own individual research topics. Each
management of specifi c disorders related author’s individual and specifi c academic
to the cervical spine and neck. The and clinical work has contributed towards
disorders covered in the text are whiplash the development and completion of the text.
associated disorders both acute and chronic, With extensive academic qualifi cations,
cervicogenic headache and cervicobrachial research positions and teaching positions
pain. These specifi c disorders can be held by each author they have all been well
perplexing and as a result diffi cult to qualifi ed to contribute to Whiplash, Headache,
manage. However the disorders are dealt and Neck Pain.
with by the authors in a manner which In support of the research which forms
is enlightening. They provide a detailed the structure of Whiplash, Headache, and Neck
clinical understanding and as a result a Pain has been the granting of considerable
greater ability for the clinical prescription of funding. This has been granted by the
more appropriate management strategies. National Health and Medical Research
This clinical understanding takes into Centre, Australia, the Australian Research
account the individual with the complaint Council, the Motor Accident’s Research
and the associated sensory, muscular and Council along with a number of other
articular systems. Management is detailed funding bodies. The granting of funding from
by way of a multimodal approach. Hence these high profi le bodies is an indication of
the authors have provided a systematic the outstanding and competitive research
approach towards a better understanding proposals presented by the authors to the
of the complexities of clinical investigation funding bodies. In addition to funding, as
and management related to disorders of the a guide to the academic level of the text,
cervical spine and neck. the authors attracted the attention of many
Whiplash, Headache, and Neck Pain national and international experts in similar
represents extensive research infl uenced by fi elds of investigation. This attention led
extensive clinical experience. The text is the towards collaborative work with different
culmination of many decades of combined aspects of the text’s presentation.
work by the fi ve authors. In particular, the For decades musculoskeletal physio-
senior author, Gwen Jull, has dedicated much therapy and the conservative treatment
of her time to developing an understanding for neck pain and associated disorders has
of particular disorders of the cervical spine been based upon the interpretation of signs
and neck based upon her clinical experience and symptoms. These signs and symptoms
and extensive research. Her enthusiasm for were assumed to be specifi c to the articular
research has been infectious, as is evident in system. In addition a diagnosis was
the post graduate physiotherapy programs purposely avoided. As a result, treatment,
at the University of Queensland, Australia. was based upon the presumption that the
In her position as Professor of Physiotherapy application of passive ‘techniques’ consisting
at the University of Queensland she has in- of applied intermittent pressure to an
fl uenced the research of many post graduate anatomical site of pain over a spinal segment,
students. This is evident in the academic resulted in the passive mobilization of
development of the other authors. However the articulation. Should there have been a
x Foreword
perceived improvement of mobility it was systems of management which are more
considered that the ‘technique’ was benefi cial appropriate to the nature of disorders of
towards the resolution of the disorder. the cervical spine and neck. Within this
While this approach had merit towards multimodal approach are included not only
the early development of musculoskeletal physical managements but consideration of
physiotherapy in the 1960s and 1970s its the psychological and psychosocial effects
blind acceptance ultimately retarded the of the disorders.
scientifi c development of the profession. As a The authors of Whiplash, Headache, and
result, the progressive development of more Neck Pain have advanced the status and
appropriate conservative managements for credibility of musculoskeletal physiotherapy
disorders of the cervical spine and neck were and the conservative management of
lacking. specifi c disorders of the cervical spine and
Without intent, this approach is at neck. They are congratulated on producing
last been challenged by the authors of a text which clearly promotes a much
Whiplash, Headache, and Neck Pain. They greater understanding of the investigation
have questioned and researched, in depth, and management of such disorders. They
certain disorders of the cervical spine and are also congratulated on enhancing
neck resulting in the presentation of a much future developments of musculoskeletal
wider range of impairments additional to physiotherapy.
those of the articular system. As a natural Bob Elvey
progression to the description of a wide Dunsborough, Western Australia
range of impairments associated with these 2008
disorders they also describe multimodal
Acknowledgments
Neck pain is a multifaceted disorder and and Dr John Quintner, Consultant Physician
the skills and knowledge required to in Rheumatology and Pain Medicine,
research in the fi eld require the assistance Perth, WA.
and collaboration of many people who Our PhD and Honours students have
have shared their expertise with us in all contributed to the research of the Unit
collaborative research in the Cervical presented within this book and we thank
Spine and Whiplash Research Unit at the them. Likewise, research cannot proceed
University of Queensland. without fi nancial support and we ac-
We would particularly like to acknowledge knowledge the research support we have
and thank fi rstly those at the University of received from the National Health and
Queensland – Professor Justin Kenardy, Medical Research Council, The Australian
who has contributed to the research into Research Council, The Physiotherapy
psychological features, Professor Bill Research Foundation, the Motor Accidents
Vicenzino, Professor Paul Hodges, Dr Tina Insurance Commission (Qld), Suncorp
Souvlis and Ms Nancy LowChoy from the General Insurance, and the Centre of National
Division of Physiotherapy, and Associate Research on Disability and Rehabilitation
Professor Luke Connelly for his health Medicine (CONROD).
economics expertise. We also acknowledge the patients we
We would also like to acknowledge treat who challenge our clinical reasoning
the collaborations of Professor Roberto and technical skills. We especially thank
Merletti and Dr Alberto Rainoldi from all the people with neck pain who have
the Laboratory of Neuromuscular System volunteered to participate in our research
Engineering and Motor Rehabilitation, projects. Without their contribution the
Politecnico di Torino, Italy; Professor Dario research program could not occur.
Farina, Professor Thomas Graven-Nielsen Finally we would like to acknowl-
and Professor Lars Arendt-Nielsen, Aalborg edge Mr Chris Stacey of Marketing
University, Denmark; Associate Professor Eli and Communications, The University of
Eliav, University of Medicine and Dentistry, Queensland, for the photography and
New Jersey, USA; Professor Michele our models for the photographs, Karina
Curatolo, University of Bern, Switzerland; O’Leary and Sabine Giesbrecht.
CHAPTER
SECTION ONE Introduction
1
Introduction
Neck pain is a relatively common complaint and affects some
70% of individuals at some time in their lives. International
epidemiological data suggest that 40% of the population will
suffer neck pain in any one year with a point prevalence of
between 10 and 20%.1 No age group or occupation appears
immune and neck pain is second only to low-back pain in
annual workers’ compensation costs.2 Furthermore neck pain
tends to be a persistent and recurrent disorder and up to 60%
of persons can expect some degree of ongoing pain for many
years after their fi rst episode.3 This has substantial effects
on quality of life. These statistics challenge clinicians of
all disciplines to improve the worth of preventive and
rehabilitative programs for cervical disorders.
Neck pain can be present in infl ammatory arthropathies
such as rheumatoid arthritis and ankylosing spondylitis, but
by far the most common origins of neck pain are benign and
relate to disorders originating in the cervical musculoskeletal
system. An anatomical source of the condition may be
evident on radiological imaging in some cases. Nevertheless,
in relation to a defi nitive diagnosis, most neck pain
presentations share a similar destiny to those of the low
back in that for the majority of patients there can be no
absolute certainty of the pathoanatomical cause of the pain.
As a result, it has been recommended that neck pain is
classifi ed only as either idiopathic (that is, there is no
apparent evident cause of the pain) or resulting from trauma
such as whiplash-associated neck pain.4 The major drawbacks
of such generic categorizations are that they falsely assume
some homogeneity within each category of neck pain. Such
categorization offers little assistance or direction for
2 Whiplash, Headache, and Neck Pain
management for the individual sufferer of defi nitive directions for precise interven-
neck pain. tions. We have conducted research into neck
A plethora of treatments have been pain, with a particular interest in cervico-
described or tested for neck pain. They have genic headache and whiplash-associated
been diverse and one approach can neck pain in the acute and chronic states.
seemingly be the antithesis of another. This The purpose of this book is to enhance
is probably symptomatic of the absence understanding of neck pain and its
of clear diagnoses and directions for management from an impairment/
management. The current scientifi c status of pathophysiological point of view. This will
conservative physical therapy treatments not be foreign to physiotherapists and other
for neck pain is somewhat equivocal but practitioners who provide conservative
evidence is growing. Systematic reviews management for cervical disorders. Their
are pointing to the evidence of benefi t of methods of assessment rely on an
multimodal approaches to management interpretive analysis of presenting symptoms
inclusive of activity, manual therapy, and and signs in the articular, muscular, and
exercise, with exercise being a key element neural systems in the psychosocial context
of any combination of treatments.5–7 of the patient to guide treatment and set
Nevertheless it is apparent from clinical management goals. What we aim to offer in
trials of neck pain patients that there are this book is a strengthening research base
individual differences in responsiveness to for the examination and management plan
the therapy under investigation, with some through quantifi cation of the impairments.
patients gaining excellent outcomes while, In support of this approach, relatively close
at the other extreme, others achieve no correlations exist between measures of
relevant benefi ts.8–10 Heterogeneity in the impairment, functional limitations, and pain
complaints and treatment responsiveness, and disability in persons with cervical spine
as is evident clinically, is the reality in neck disorders.11 A precise understanding of the
pain patients. problems presenting in the various systems
This equivocal picture of neck pain gained from research provides the directives
realizes the importance of moving in new and rationale for treatment methods.
directions for the diagnosis and manage-
ment of the neck pain patient. The neck Structure of the book
is an intricate structure anatomically,
neurophysiologically, and biomechanically. This book emanates directly from our
Neck pain patients may complain of a research and clinical interests in neck pain
myriad of symptoms with and without and does not pretend to be a comprehensive
attendant psychological features or dissertation on cervical musculoskeletal
reactions. We have taken what could be disorders. Rather the initial section presents
termed a pathophysiologically based the basic and applied clinical research that
approach to identify better the processes we and others have undertaken into neck
in the sensory and motor systems, in pain disorders. Pain mechanisms and
sensorimotor function, as well as the measurement of sensory disturbances will
psychological features that are associated be highlighted, providing insight into neck
with neck pain and other associated pain for both assessment and management
symptoms. Understanding and quantifying purposes. Comparisons will be made
what is happening to the person and to the between whiplash-associated disorders and
sensory, articular, and muscle systems with idiopathic neck pain throughout the text as,
neck pain have the potential to provide although there are many similarities in
CHAPTER
Introduction 3
underlying processes in these categories of defi cits in a clinical situation will be
neck pain, there are differences, especially described, as will be the implications for
in relation to pain and changes in the sensory management and the research base for the
system as well as sensorimotor control. design of therapeutic exercise interventions.
The evidence supports the important role Current knowledge of the role that
of exercise in the rehabilitation of the neck psychosocial factors play in neck pain,
pain patient. This fi eld has been one of our especially in whiplash-induced pain, will be
particular interests and will be emphasized explored. It seems that the psychosocial
in management of persons with cervical factors involved in neck pain may differ
disorders. In a lead-up to the therapeutics, somewhat from those in low-back pain,
the anatomy of the cervical and axioscapular which fl aws automatic extrapolation of
muscles and related biomechanics and chronic low-back pain data to neck pain for
pathomechanics will be presented. There the purposes of diagnosis and treatment.
will be an emphasis on applied anatomy of In the next major section of the book, we
the articular system and the muscles’ role in present three common conditions that have
movement as well as support for the cervical been our particular interests in research.
and axioscapular regions. Our research into These are whiplash-associated disorders,
the nature of impairments in the muscle cervicogenic headache, and cervicobrachial
system associated with neck pain has pain. Whiplash-associated disorders
highlighted the properties of muscle continue to present major challenges to all
disturbances that have been determined in those involved in its management. The
neck pain patients, including, importantly, mechanisms of injury will be reviewed in
alterations in muscle coordination, muscle relation to their possible injury sequelae.
fatigability as well as loss of strength and Whiplash-associated disorders are marked
endurance. We will present original evidence by their heterogeneity in presentation, which
of disturbances in patterns of muscle control, realizes the importance of understanding
which implicate regular disturbances in the the variety of impairments that may present
deep pre- and postvertebral muscles. This as well as indicators of prognosis.
research provides the basis for the design of A classifi cation system will be provided
therapeutic exercise interventions presented for whiplash-associated disorders based
in this text. on identifi ed physical and psychological
Other elements of disturbed sensorimotor disturbances shown to be present soon
control will be explored. The case for the after the injury. It provides directions for
role of disturbances in cervical somato- the early diagnosis and management of the
sensory information to the sensorimotor whiplash injury. The chapter on cervicogenic
system as well as the resultant disturbances headache will have a focus on the differential
in cervical joint position sense, eye movement diagnosis of cervicogenic headache from
control, and balance will be presented in other frequent intermittent headaches,
association with other elements such as the notably migraine without aura and tension-
vestibular system. The neurophysiological type headache. It will present research
basis for symptoms associated with neck investigating the role of musculoskeletal
pain such as dizziness, light-headedness, impairment in frequent intermittent
and unsteadiness, as well as attendant headache as well as a comprehensive
physical impairments which are particularly description of the impairments in the cervical
common in chronic whiplash-associated musculoskeletal system which characterizes
disorders will be explored. Assessment cervicogenic headache. In discussing
methods that can be used to depict the cervicobrachial pain, processes involved in