the cervical and thoracic spine - mechanical diag., therapy 2nd ed. [2 vols] - r. mckenzie, s. may...

8/17/2019 The Cervical and Thoracic Spine - Mechanical Diag., Therapy 2nd ed. [2 vols] - R. McKenzie, S. May (Spinal, 2006…

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THE CERVICAL &

THORCIC SPINEMECHICAL

DGNOSIS &

THEPYVOLUME ONE

RBI CKZIZ ( Z (

STPH y c


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THE CEVCA & TOACIC EMECHAICA DAGO & THEAY

BY ROBIN McKENZIE AND STEPHEN MAY

This bk s essenial ading for any heath pfena invled in the mnagemen patiens wth cevca r thcic pan. Desd wthn are he mechancal measeqd fr he dagnis and men f th commn pblem he pci denfan and magement f subgrps n the scum mechcal eical and hracic dseshas been d be a prry f we are t mprve r methds managemen f bac andneck prblems hs las b in he es by McKenze and May prdes a ystem idei sbps and cnseqenly pde e stegc sl

Rbin Mcee fit pblhed h landmark ex uining cen prncples and cncepsf he dagnss and management mba spine probems n Anher me adding the cevic and thcc spine w pubshed n . H s pbicans alwys stsd he imporance f paten sef-management and the reeance f hi se been belaedly ecgnd by the Since the pblcatOs cnsiderabe evdence hdemsred the mace and leance th pincples and nep i t memagement f mlokelea poblem

hs edn exps the centn and phealiin phenmena; he u exe indce changes in pan ain and nensity; he means f deectng he ms eeciedcn n whch t appy theuC exe; d erentan

dspacemen pan f cnacure and pain asng rm nm sse; hw t d eniatethe pain nee o adhence fm enpment and aca

hs econd edion f eca hracc Spne: Mechania Diass hepypaaels he changs in the upded Lumba Spine text I been hughly vd andndeby xnded and expl n depth he lieture lang mechan ydmes and neck and trun pn n genea he ae deiptins of he mnagement of he thremechanica sdrmes deangement dysunctn and pstal sdrome s appled tneck thacc and headhe prbems here s ndeph csidertin the ierarelatng a number f ses sch as he epideml neck pan headaches rs

spl paholgy and whiplsh. peal dens deptis and nme tablespvde clncal sis and sympms t cgne r sspc mechancal sdomes he dagns

Rbn McKenzie and Sephen May hae prdced anthe eidencebad and clnicallyant txt r th nw nty umntn h hr ume avlbl th rlat t thelmbar spne and >1my pblems I pdes a review f levant gene tpcs as wel as he dea f hw t evauae and pscibe apppae specc execses and manatechniques he sysem debd in his bk acheves a new bnchma he nnsgcal management mechaa ceca and thrcc drdes


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T Crv & Tr Dgss & Tr

Vlum O

Robin McKenzeCNZM, OBE FCSP (Hon) FZSP (Io) DT Oil MT

Stephen MayA Mp O' c

Spinal Publcatons ew Zeaand LtdRamat Beah, New Zealand


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The Ceical Thoacic Spie: Mecaica DiagosIs & herapy

Fit Edtion rst pubsed 1990 by Spinal Pbiaton New Zand td

ecod dton st publshed in April 2006

Reried ebruay 2007, Mac 2008 by

Spial Pbicatons ew Zealand Ltd

PO Box 2026 amati eac ew Zealand

mai [email protected]

© ob McKenie 2006

l rhts reserved o pa of this pblicaon may be repduced byany means, stoed in a eteva system or ansmitted in any orm or by

any meas electoic mecaical inldng potocopyng ecod o

otherwis wthot te pior witten pemissio of he p)ht od

SB 0 0-9583647-7-X

SB 3 978-098367-7-5

esign by et Communcatios

dited by Atmnwood Edtn and Ja McKie

hotoaphy by Jon Ceese

lstratios by a ug

ypeset ad pinted by Astra it


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c

o my patents who from 95 to taught

me al kno


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iv Foreword

The lumbar pie ha wo coui he cervica pe whch he

p oor coui ad the horacc pie which i the eve poorer coui

hey are poor becaue they have o ltle cece Wherea he umbar

pie ha bee exte ively tuded ad ome might veture tha t i

eve reaoably we uderood thi i o the cae for he cervica

ad thoracc pie

Some thg are kow about the cervcal pe We kow it tructure we kow how t work we have ome dea about how t ca be

ijured We have ome udertadig of he orgi ad caue o

eck pa.

The ame cao be ad about the thoracc pie. We have ltte

iight ito how the horacc pie work. We have eetially o

kowedge of the commo caue of horacic pia pa Variou

c oj ecture have bee brough to bear b u oe accopaed by

cetic daa

Wh re pec o treatmet we have e ough tude o how that for

acute eck pai mo iervetio d o o work Keepg he ec

active i the oly erveio ha ha bee h ow o be efecive. For

chroc eck pa we have itle data For horacic pia pai eiher

acute or chroc he literature i devoid of ay cetc data

It i io thi evirome that Robi McKee ed he ecod

ed tio o hi text I thi edito he reiterate h ciical protoco

bu e i i the coex o what ee kow about cervcal ad

thoracc pal pai

he ex provide a thorough ad farly compreheive review of the

backgroud lerature. Reader are appred of what i ow about

the epidemiology ad rik facor for eck pa ad the litle that i

kow abou horacic pal pai. articularly valuable for phyica

herap are utable acc ou of the eri ou cau e o cervical adhoracic pial pa ad a accout o vertebral arery d order ad

heir rec ogtio

hee acc out reect what i avalable i the l eratue Cotrbuo

to hat literature have focu ed o what might be c otrued a the eay


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aspects of spine pain: counting its prealence, descibing ts nature,

and reporting seious causes Whie auable , hese actiities n onethe

less fai o address he preailing prolems: what are the commoncauses, and what bes should be done ab ou them

McKenzie d oes not proide a s oluton. F or something t o be a s oluion

requires eidence of reliability, alidity and efcac These remain

acking for neck pan and nonexsten for thoracic spinal pan The

tex recognises that, but d oes refer to he sma handful of studies

hat hae been underaken

What McKenze does prode is an approach I n a eld where he e isno c opet t on, where here is no proen me hod one can argue that

any approach s not onaly al d Its irtue s tha it c ombats nihi sm

by giing reade s a rm proocol to folow. This ab oe all m ght be

the critical therapeut c ngredient

To date, no studes hae shown that his proocol is alid, ie hat

the syndroes described eally do exist and c or espond t o s ome

sot o eried pathology, be that suctual or phYiologica Nor

has been estalished ha he specics o he potocol achiee

unique and superio outcomes. We do not know if derangement and

dysfunction mean anything more than idiopathic neck pain We do

not know i f their specic de ect ion and treatment is any m ore efec

tie than comparatiely arbi rary exercises o keep the neck m oing

Especially we do n ot know the exent to which patients respond and

benet fro condent, conincing explanations and concerted care,

irespectie of conten; ye t is that condence tha he McKenzie

protocol poides

As eaders and pracitoners exploe the McKenie protocol hey

should remain openminded. The protoco arms them with something

pragmatic to do, e to get on wih managing paients is highly

likely that they will mee wih success sufiently oten o enc ourage

them to c ontinue using the prot oc ol yet they should n ot c onclude

tha this success is due to the specics o the prooc ol . Simply being

a good ca ing practtioner may e he actie ngred ent n o maste y o a paticular ca echism of actiiy and in erention. ract ioners

should remain open to the possibiliy that t s the condence and

care that they express that generates their resuts

v


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hi uncertainty hod alo be the propt or McKenzie therapit

to catch up wih he reearch agenda. They have no ground for

coplacency in hi arena They have produced a good dea of

reearch on lubar pinal pan I ha not been atched for neck

pain or horacc pinal pain If the McKenie protocol i o l he

therapeuic vacuu for neck pain and thoracc pnal pain it need

the accopanying cience to deontrate reliability validity and

efcacy which will proote i fro a good idea to evidence-baed

practice

koai Bogdk BSc (Med), MBBS MD Sc ip Anat ip Pn Me FAFRMAFMM FFPM ANZCA

roeor of ain Medcine

Univerity of ewcatle

Royal ewcale Hopa

ewcatle Autralia


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Acknowledgments

woud ke to give peca thak to y coauth o ried ad colleage

Stephe May MA MCS D MT MS who ha wligy provided hi

tie ad expertie to ake thi ecod edito a evidece-baed

text of iportace toal health profeioal volved o- operatve

care of he ppe back ad eck

a ao greaty idebted to he ay faclty of the McKeie tte

teraioa who have ether directy or directly ueced the

eeet that have bee ade o the decrpto of the procedure

o aeet ad exaiatio The va e of thee cotribut o i

ieaurabe

woud alo ike to expre y grati tude to Hee C are the titute

irector of ducato Kathy Hoyt ad Grat Wato who gave o

uch of their t ie to read the a cript ad povde valuabe

coetary ad cri ici .

Fiay to Ja y daughter who ha o well aaged ad coodiated

he va ou peciait eqired to ucce fully cop ete thi aj or

tak 1 give y grateful thak

Robin McKenzie

Raumati Beach

New Zealand

Aprl 200

Vii


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viii About the Authors

Robin McKenzie wa b orn n Auckland New Zealand n 1 3 1 and

graduated from the New Zealand Schoo of Phyotheapy n 5

e c ommenced priate practice n Welington New Zealand in 1 53

pecial iing in the diagnoi and treatment of pina di order

ring the 1 60 Robn McKenzie deeloped new concept of dagnoi

and treatment dered from a ytematic analyi o patient wt both

acute and chronc back problem Th ytem i now practied gobay

by pecialit in phYiotheapy medcine and chopactc

he ucce of the McKenzie concept of diagnoi and treatment for

pinal poblem ha att acted nteret from reeacher worldwide

The importance of the dagnotic ytem i now ecognied and the

extent of the therapetic efcacy of the McKenzie Method i ubject

to ongoing inetigation

Robn McKenzie i an on oray Lfe Membe of the Ameican Phyica

Therapy Aociat on "in recognit on o di tinghed and merit orou

e ice t o the art and cence of phyical therapy and to the welfare

o manknd e i a member of the Internationa Society for the

Stdy of the Lumbar Spine a Fellow of the American Back Society an

on orary Fellow o the New Zealand S ocety of Phyiotherapit an

onorary Life Member of the New Zealand Manipuatie Therapit

Aociation and an onorary Fellow of the Chartered Society of

PhYiotherapit in the United Kngdom In the 1 0 Queen Brthday

on ou he wa made an Ofce of the M ot Excelent Ode of theB iti h Empire In 1 3 he receied an onoary oct oate from

the Ruan Academy o Medica Science In the 000 New ea

on our Lit er Mae ty the Queen appointed Robin McKenzie a

a C ompani on of the New Zealand Order of Mert

In 00 3 the Unierity of Otago in a j oint enture wth the McKenzie

Intitute nternationa ntitted a Potgradate iplomaMate

p ogramme end ored in Mechanica agnoi and The apy® Robin

McKenzie ha been made a Felow in Phyotheapy at Otago and

ect e drng the progamme


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Contents

CHAPTER ONE

CHAPTER TWO

CHAPTER THREE

OS xi

OLUM O

Introduction . . 1

The Problem of Neck Pain . . . . . . . 5

troducto . . . . . . . . . . . . . . . . . . . . . . . 5

revaece . . . . . . . . . . . . . . . . . . 5

atura ht ory . . . . . . 7

Severty ad dabity. . . . . 8

Heath careeekg . . 9

Ri facor . . . . . . . . . . . . . 9

Oe . . . . . . . . . . . . . . . . . . . . . . . 2

rogoic factor ..... . . . . . . 2

Cot 3

Treatmet e fectvee . . . . . . . . . . . . . . . . . . . . . 3

Cocuo. . . . . . . . . . . . . . . . . . 5

Pain and Connective Tissue Properties . . . . 7

trod ct o . . . . . . . . . . . . . . . . . . . . . . . . . 7

N ocicepio ad pai . . . 8

Sorce of eck pai ad cervica radc opathy . 9

ype of pa . . . . . . . . . . . . . .20

Acivaio of ocicept or . . . . . . . . . . . .28

Mechaica ociceptio . . . . . . . . . 2 8

Chemica ocicep io . . . . . . . . . . . . . . . . . . 2 9

rauma a a cae o pai . . . . . . . 30

Di iguihig chemca a d mechaica pai 30

Te repair proce 3

Faure o remode repair iue . . . . . . 3 7

Chroc pa ate . . . . . . . . . . . . . . . . . 3 8

Coco. . . . . . . . . . . . . . . . . . 4 3

Cervical Anatomy, Ageing and Degeneration . . . . . . 4 5

Itrodct o . . . . . . . . . . 45Cervica aa omy . . . . . . . . . . . . . . . . . . . . . . . . . 45

Vertebrobai ar artery . . . . . . . . . . . . . . . 47

Ageig ad degeeraio . . . .

Morphoogy uctio ad pahoogy ... .

. . . . 48

49


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xii

CHAPTER FOUR

CHAPTER FIVE

CHAPTER SIX

CHAPTER SEVEN

CHAPTER EIGHT

Cervical aatmy ad the McKee cceptua mde . . . . . 50

Cclui . . . . . . . . . . . . . . . . . . . . . . . . 5 3

Movement and Biomechanics of the Cervical Spine 55trduci . . . . . . . . . . . . . . . 5 5

Rage f mvemet . . . . . . . . . . . . . . . . . . . . . . . . . 5 5

Factr that affect he rage f mveme. . . . . . . 5 6

Effect f pture cervical pie . . . . . . . . . . . . . . . . . . . . . . . . . 58

Rle f ucae prcee . . . . . . . . . . . . . . . . . . . . 5 9

Effect f mvemet tucture . . . . . . . . . . . . . . . . . . . 5 9

Uppe cervical bimechaic . . . . . . . . . . . 6 1

Suaied ladig ad ceep 6 1Ccui . . . . . . . . . . . . . . . . . . . . . 63

Diagnosis and Classificaton . . . . . . . . . . . . . . . . . . . 6 5

Itrducti . . . . . . . . . . . . . . . . . . . . . . 65

Seekig path-aatmica d iage . . . 6 5

Cla icati y tem . . . . . . . . 68

Diagt ic t riage . . . . . . . . . . . . . . . . . . . . 70

Sub-grup ideticati dicati ad ctraidcai

f M DT . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72Cclu i . . . . . . . . . . . . . . . . . 73

Mechanical Diagnosis . . . 7 5

I r duct . . . . . . . . . . 75

Deragemet ydrme . . . . . . . . . 75

Dyfuci ydrme . . . . . . . . . . . . . . . . . . . . . . . . . 77

Ptual ydrme . . . . . . . . . . . . . . . . . . . . . . . . . . . 79

Cclu . . . . . . . . . . . . . . . . . . . . . 8 1

Literature Review . . . . . . . . 83

trduci . . . . . . . . . . . . 8 3

Efcacy udie . . . . . . 83

Mechaically deermied direcial prefe ece . 86

Cetraliat i . . . . . . . . . . . . . . . . 88

Reliabity . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89

Prevalece f mechaical ydrme i eck pai paiet 90

Cclui . . . . 9 1

Serous Spinal Pathology . . . . . . . . . . . . . . . . . . . . . 93

It ducti . . . . . . . . . . 93

Idet cat f eriu pal pahlgy . . . . . 94


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CHAPTER NINE

CHAPTER TEN

CHAPTEREEVEN

OE ii

Cancer/umour . . . . . . . . . . 96

Horner' ydrome . . . . . . . 97

Spina c ord . . . . 99

Fracture and d l ocaton . . . . . . . . . . . . . . . . . . . . . . . 1 04

Ote op o oi . . . . . . . . . 1 0 6

Spinal infection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 0 8

Rheumatoid arthriti R . . . 1 09Ankyl oing p ondylii . . . . . . . . . . . . . . . . . . 1 1 0

Upper cervical intability . . 1 1 0

Exreme diine/vertigo . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 12

Cevica pine and verebobaar inucency VB . 1 1 3

Caotid a ery path ol ogy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 25Concuion 126

Oer Dagnosic and Managemen Consideraions . . . . . 1 27

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 7

Cervical and thoacic ygapophyeal j oin pain . . . . . . . . . . . 12 8

Shoulder pan 1 3 3

Mechanically inconclu ive . . . . . . . . . . . . . . . . . . . . . . . . . . 1 3 5

Chronc pain . . 136

Cervica pondyoi/enoi . . . . . . . . 1 3 9

Cervica radiculopahy . . . . . . . 1 42

Surgey fo cervica and thoracic probem . . . . . . . . . . 1 46

Pot -urgery . 1 48

Thoracic Outle Syndrome . . . . . 1 48

Concluion. . 1 52

Te Hsoy 1 5 3

Intoduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 5 3Aim o hit ory-ang 1 54

ntervew . 1 5 5

Patient demographic . . . . . . . . . . . . 1 5 5

Symptom thi epi ode . . 1 57

Previou h it ory . . 1 6 7

Specic queion 6 7

Concluon. . . . . . . . . . . . . . . . . 1 70

Pysical Examinaion . 7 1Introdcton . . 1 7 1

Aim of phyical examination . . 1 73

Sitting poure and i effect on pan . . . . . . . 173

Neurol ogical examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 76


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CHAPTER

FFTEEN

CHAPTER

SXTEEN

CHAPTER

SEVENTEEN

CHAPTER

EGHTEEN

OS xv

Cinical Reasoning 2 6 1

roducion 261

Cical reaoing . . . . . . . . 262

Eleme ha inform he clincal reaoing poce 263

Daa-gaherig. . . . . . . . . . 26 3

Kow ledge bae 264Cliical expeence . . . . . . . . . . . . . 2 65

C ogio and mea-cogion 265

Error in cli cal reaoig 266Cliicia ba 267Mechaical diagnoi ad herapy ad clinical reaog 26 7

Example of clinical reaoing proce 269Concluio . . . . . . . . . .. 282

Recurences and Pophylaxis 283

nroducio . . . . . . . . . . . 28 3

reveaive aegie 284

Fu u e epi ode 285

Evidence 286

Cocuio 286

OLUM TWO

Management of Deangemen Pinciples 289

roducio 289Sage of manageme 289

Manageme pricple 298

Treamen pahway in derageme .. . . . . 307

Concuion . . . . . . . . . . . . . . . . . . 309

Managemen of Deangemen Cenral and Symmetical

Sympoms (prviously Dangmnts 1,2 and 7 3 1 1roducio 3 1 1

Exeio prnciple 3 1 1

Deformiy of yphoi (previouly Derageme 2 . . . . . 3 6Flexion prciple (previouly Derangemen 7 . . 3 1 8

C onclui on . . . . 3 1 9


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x O

CHAPTER

NNETEEN

CHAPTER

TWENTY

CHAPTER

TWENTY-ONE

CHAPTERTWENTY-TWO

Management of Derangement Unilateral and

Asymmetrcal Symptoms to Elbow

pviously Dangmns 3, 4 an 7 32Introduction 32

Assessmen determining the approp iate stategy 322

Ident icati on of laeral c omp onent 328

Management ateral c omp onen n o lateral deviation 329

Management aeral comp onent wih aeral deviation

wry nec or acue torticolis 332

Fexion principle 334

Conclusions 336

Management of Derangements Uniateral or

Asymmetrical Symptoms Beow the Elbow

pviousy Dangmns 5 an 6) 339Introduction 339

Differenia diagnosis 340

Determining the appropriate l oading sraegy 343

Management when deformity is present 350

N on-resp onders o mechanical diagnosis and therapy 35

Conclusions 352

Cervica Dysfunction Syndrome 353

Intoduction 353

Categories of dysunction 354

Pain mechanism 355

Clinica picture . . . . . 358

Physical examination 360

Management o dysfunction syndrome

36Instrucions t o all patients wih dysfunct ion syndoe 363

Management of extension dysfunction... . . . . 3 64

Management o flexion dysfunction 365

Management of otation dysfuncton 368

Management o laeral fexion dysuncion 369

Management o multiple direction dysfunction 370

Conclusions 3 7

Dysfunction of Adherent Nerve Root (ANR) 373Int roduc ion . . . . . 3 73

Developmen of adherent nerve roo 373

Clinical presentati on 375

History 376


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CHAPTER

TWENTTHREE

CHAPTER

TWENTFOUR

CHAPTER

TWENTFIVE

N xvi

hy ical examinaion . . . . 3 7 7

pper imb tenon e and differentiation o derangement

a n d A R . . . . . 378Management 380

rocedure for treaing adherent nerve root 3 8 1

Concuion 3 82

Postural Syndrome 383

Introduction 383

ain mechanim . 384

ffect of p oture on ympom in n ormal p opulat on 385

Clinical picture 387hyical examination 3 8 8

oure invoved 390

Managemen of poural yndrome 39

otural yndrome aggravating fact or itt ng 392

otural yndrome aggravating factor ying . . . . . . 397

oural yndrome aggravating factor anding 398

Management of poural yndrome . . . . . . . . . . . . 398

Conequence of poural neglect 399

Concluion . . . . . 400

Headache 401

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . 40 1

pidemiology of headache 402

Cau e of headache 403

Differential diagnoi 406

Cervicogenic headache 408

Neuroanaomy of cervicogenic headache and experimenaevidence . . . . 409

Mechanica diagno and herapy and headache. . . . . 4 1 0

Claication . . . . . . . . . . . . . . . 4 1

Hitory 44

hyical examination 4 1 5

Mechanica aement 46

Managemen of mechanical cervical headache 4 1 7

Concuion 4 1 9

Cervical Trauma or Whipash Associated Disordes 421

Int roducti on 42 1

What i whplah ? 422

whiplah rea 423


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xvii I CONTENTS

CHAPTER

TWENTY-SIX

CHAPTER

TWENTY-SEVEN

CHAPTER

TWENTY-EIGHT

CHAPTER

TWENTY-NINE

CHAPTER

THIRTY

Signs and symptoms 45

Classi cai on of WAD 46

Natual hist oy . . . . . 7

Pognostc fact ors 48

Managemen of WAD teature 49

Management mechanica diagnosis and herapy 43

Conclusions 434

Thoracic Spne Epidemiology, Pain, Anatomy,

Bomechanics . 437

nt od uct ion 437

Thoracic epidemiology 437Thoracic pain 438

Thoracic anaomy . . . . . . . . . . 440

Thoracic b iomechanics . . . . . . . . . . . . . . . . . . . . . . . . . 44

Abnomal morphoogy . . . . . 443

Conclusions 445

Classification of Thoracic Spine Problems 447

nt roduction . . . . . . . . . 447

Seri ous thoracic spina path ol ogy 447Mechanical syndomes 448

Other categoies . . . . . . . . . . . . . . . . . . 449

Scheuermanns disease 450

Conclusions. . . . . . . . . . . . 45

Thoracic Spne Assessment 453

nrodcton . . . . . . . . . . . . . . . . . . . 453

Hstory 454

hysical examinati on 456

Sta tc mechanical evauati on 46

Concusions foowng the examnation ... 46

Conclusions 463

Procedures of Mechanical Therapy for the Thoracic

Spine . . . . . . . . . . . 465

Int oduction . . . . . . . . . . . . . 465

The procedures . . . . . . . . . . . . . . . . . . . . . . . 465

Thoracic Derangement Management 479

ntroducion . . . . . . 479

Management of cental and symmetrical symptoms 79


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CHAPTER

THIRTYONE

O E S xx

Eteio priciple 480

Paiet eiew .

Maagemet of aymmerical ad u latera ymp om

Extei o pricple . . . . . . . . . .

. . . 482

484 . .484

aeral teatme prcple . 488

Cocuio 489

Thoracic Dysfuncon and Posural Syndrome

Managemen . . . . . . . . 49 1

Itroductio 491

Dyfuctio ydrome 491

Potual ydrome 495Cocluio 497

Appendix 499

References 507

Glossary of Terms . . . . . . . . . 5 45

ndex

. . . . . . . . 5 55


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Lst of Tables

1 1 Prvalnc nck pan in gnral ppulain studis 6

1 . Prvalnc prsistn nck pain in gnral ppulatin 8

1 Basic pain typs . . . . . . . . . . . . . . . . . . . . . 0

Ky actrs i n pain idnticatin 3 1

. 3 Stags haling apprximat timram . . . . . . . . . 3

4 Chrnic pain sats 3 9

5 Charactristics chrnic pain syndrm . . . . . . 3 9

6 Pan-gnrang mchanisms . 43

51 Typical sgns and symptms assciatd wih nrv rt

invlvmnt . . . 7 1

8 Rd lags that may indicat srus pathlgy in nck

and thracic pain patints . . 95

8 .2 Sgns and symptms assciatd wth spina crd lsns

in th crvical and thracic spin 04

8 .3 Suggsd ndicars r invsigain llwng trauma 10 58 Unxplaind r nw ns symptms that may ruir

mmdiat mdcal atntin . . . 1 1

8 .5 Clnical aurs assciad with vrtbrbaslar

insucincy r vrtbral artry dssctn 1 16

8 6 Drntiatin bwn dizzinss crvical r thr

rigin . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 17

8 7 Mchanica dagnsis and thrapy and saguards with

VE 1 4

8 . 8 Physica xamnatn scrnng tsts r patints prirt manipuan . . . . . . . . . . . . . . . . . . . . . . 1 5

9 1 ntrtstr rliabiity xaminatin by palpatin in th

crvical and thracc spin ... . . . . . . . . . . . . . . . . . . . . 1 3 3

9 Drntial diagnsis crical and shuldr prblms . 134

9. 3 Charactristics chrnic pain syndrm . . . . . . . . 137

94 Ky [actrs in idntcatin chrnic pain stat . . . . . 1 38

9 5 Rliability and validity physical xaminatn r

crvical radicupathy . . . . 1 4 5

10 1 Symptm pattrns rlvant t managmn dcsins . . . 1 57

10 Dnitins acut sub-acut and chrnic . . . 159

F B Ixxi


24/600

xx I F TA BL E S

0 Criteria r deg sas cdi . . . . 160

0 4 Features hstry red lags) hat may dicate seris

spial pahgy . . . . . . . . . . . 1 69

1 1 . 1 Cductg a eurlgcal examiai 76

1 . Typca sigs ad sympms assciated wth eve rt

ivlvemet . . . . . . . . . . . . . . 177

1 imesis sympmaic preseati mt

prgress 00

1 Crieria by which paraesthesia may be mprvig . 0

Trac Light Gde t symptm respse bee dig

ad ater repeaed mvemet testg . . . . . . 06 4 mesis mechaica presetai by whch

assess chage . . . . . . . . . . . . . . 0

1 5 Cmmly used eck disabity uestaires . . 1 1

1 . 6 Mechacal respses t ladig saegy . 1

1 . 7 Chaacerstic symptmatc ad mechaical presetatis

the mechaica sydmes . . . 1

1 . 1 ieret methds clayig symptm espse . . . 1

1 Ma eemets review prcess 1 4 1 Frce prgessi . . . . . . . . . . . . . 6

1 4 rce alteraives . . . . . . . . 6

14 Treame pcples . . . . . . . 9

1 4 4 rcedues al i rder rce prgresss) . . . . . 9

7 1 Stages maagemet derageme . . . . . . . . . . . 90

7 Recvey ci esurig stabity

deagemet . . . . . . . . . 96

1 7 Teatmet priciples . . . . . . . . . . . . . . 991 7 4 Clues as t eed r extes priciple (no all wll be

pesen . . . . . . . . . . . 00

7 5 Exesi priciple rce prgressis ad rce

alteraives . . . . . . . .

1 7 6 Idicats r csiderati latera cmpet

1 7 . 7 atera devati cervical spie deiis . . .

1 7 Clues as eed r lateal priciple (no all wll be

peen) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

17 9 ateal picipe rce prgressis ad ce

. . 0

0

04

.04

aeratives . . . . . . . . . . . . . 05

1 7 1 0 Cles as t eed r lex pricipe (no all wll be

pesen) . . . . . . . . . . . . . . . . . 06


25/600

7. Flxin pncipl c pgssns and c

alnatvs . . . . . . . . . . . . . . 306

7 Clus ducb dangmnt nt all wll be present)

3079 . Rspns t xnsn cs n unaal asymmtcal

symptms and implicatins . . . . . . . . . 33

9. Ctia a lvan latal dvatn 333

0 Cus t th dntial diagnss btwn dangmnt

stnsis and adhn nv t . . . . . . . . . . . . . 34

0 Rspns t xtnsn cs n unlatal asymmtical

symptms and mplicatins . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 4 5

. Atcula dysunctn syndm ctia all wll apply 3 6

nsucns t patnts wth dysunctin syndm . . . . 363

3 Rcvry uncn nsuing stabliy dangmn . . 366

. Adhnt nv t cinical psntan all wll apply) . . 376

Cita dniin adhnt nv t all wll apply . 30

3 . stual syndm cta all wll apply . . . . . . 39

3 Managmnt pstual syndm . . . . . . . . . . . . 39

4 inial diagnss hadach . . 4034 ssbl d ag' ndcats sius pathlgy in

hadachs. . . . . . . . . . . . . . . 404

43 iagnstic ctia migan withu aua and pisdc

nsn hadach . . . . 406

44 ssbl clus t mchancal nau cvcgnic

hadach . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 5

5 snting sgns and symptms m whiplash . . . . . . . . 45

5 QTF casscan WA

. . . 4 66 ndicas muscuskltal caus abdmna pan 440

9 cdus . . . . . . . . . . . . . . . . . . . . . . . 466

30 Rspns t xtnsn cs in unilata asymmtica

and mplica ins . . . . . . . . . . . . 45

3 Aticula dysunctin sydm cta all wll

apply 49

3 nstuctns patins wh dysunctn sydm 493 3 sua syndm cta all w apply . . . . . . . . . 495

3 4 Managmnt psual syndm . . . . . . . . . . . . . . . . . . 496

F B Ixx


26/600

xiv I


27/600

ntroducton

It s twnty-v yas snc th rst bk n th McKnz Mthd

The Lmbar pe Mehaal Dagoss Therap, was pubshd

and vr tn snc th rst dtn ths txt dscrbd th systm

as t appld t th crvca and thracc spn. Much has changd

n th ntrvnng uartr cntury n th wld spn car. It usd

t b that clncans whthr physca thrapsts chrpractrs r

stpaths dspnsd tratmnts that ncludd hat lctrthrapy

mdalts massag and manpulatv thapy t manly passvpatnts as many tms as th clncan cnsdrd apprprat.

Manual thrapsts wrkd t whchvr spcc mdl j nt dys

unctn thy adhrd t whthr hypmblty jnt xatns r

stpathc lsns. Th bpsychscal md pan had yt t

b bn th mptanc patnt nvlvmnt n managmnt had

nt yt bn rcgnsd and th trm vdnc-basd hath car'

was unknwn. Br ths trms bcam amlar t all th systm

mchancal dagnss and thapy prvdd a structurd and lg

ca mans cntrlng mchancal spn pan that allwd patnts

t b at th cnt managmnt Ths s stll th cas tday and

n th ntrm th vdnc t supprt and vndcat th apprach

cntnus t accumuat

Th scnd dtn The Cerval Thora pe: Mehaal

Dagoss Therap stll prsnts th lgcal and structurd

apprach t th assssmnt classcatn and managmnt nck

and trunk prblms st dscbd n 1990 Th charactrstcsassssmnt managmnt and clncal rasnng asscatd wth

th mchancal syndrms drangmnt dysunctn and

pstural syndrm ar dscrbd As th rcgntn srus spnal

pathlgy s mprtant sa pactc th lmtd ltatur avaabl

that dscbs d lags n th cvcal and thracc spn s psntd

Th matra has bn thrughly updatd an d xpandd t nclud a

gnra ntrductn t nck pan pblms that wll b rlvanc

t all wh trat ths patnts Ths ncluds a rviw pdmlgy

pan and vant bmchancs and pathphYlgy Thr ar

cntmpary and dtald rvws hadachs and whplash

dtalng th usulnss and mtatns mchancal dagnss and

thrapy n ths aras.

R D


28/600

2 1 ' ROUCO R VCA & HO RA C P I NE : M CHA N A L G OS S & H RA Y

Researc regarding lumbar spne prbems is ar mre abundan an

tat relating te cervica spine and s appies bt e general

lierature as well as te lierature reevan mecanica diagnsis and

erap Nneeless, t ere is ncreasing researc nt varius aspecs

relevan neck pain, and te present vlumes use is abundanl

wever, s imprtant neier t ake all researc a ace vaue nr

slavsly accept all current researc deas

Tere as been a recen rend empasise te psycscia

cmpnen back and nec pan Te researc int is evdence

base is extensive, but en ails accun r er impran

prgnstic actrs suc as centralsat in; ais accun r sudies inwic pan ges be er and te psycscia acrs disspate a s

determne te psycscial acrs require treamen drected a

tem; and ais t distingus beween dieren degrees psycscia

actrs Alug psyclgica eaures e spine pain experience

are imprtan, ese ave rarely been examined in cnjuncin wt

bmedical aspecs. Wen ey ave, cenralisain/nncentrasa

in caegres ave been und t be mre imprtan predicrs

lngterm utcme an earavidance, depressin, smaisain

and nnrganic signs. Few trals ave been cnduced n wic

cassicatin sysem-based treament as been cmpared guidelne

based reament, bu wen tis as been dne targeed reamen as

demnstrated beter ucmes an gdelineed reamen ere

is muc urter researc be cnducted, especaly pertaining

te cervcal spine, bu recent researc cnnues t glg e

reevance cenrasain and casscained managemen r al

nnspeic spna patiens

Twentyve years ag, wen The Lubr Spine Mehnil Dignosis

Therpy was pubised , i presented a lgica sysem assessment

and managemen dreced a mecancal syndrmes wi an

accmpanying cncepual mdel Te cnceps were exended t

ncude te cervical and tracic spine in 1990 and e extremies

n 000 W te updaing The Cervil Thori Spine

Mehnil Dignosis Therpy te ngng relevance ese

cncepts in e s century is apparent t prvides a srucured

system eamnatn and managemen mecanica syndresne at is patiencentred and indirectly aecs e psycgical

aspects a spine pain episde; ne a is alert e epidemilgica

aspecs spine pan as i empasises semanagemen and a


29/600

ROD U O

syste tha pers early recgnn fnnespndes and red fags'

when classicatin int a echancal syndre fails t be ade The

astnishing pescence the syste f echanical diagnsis andtheapy is ny truly recgnisale in hndsigh.

Robn MKenz e

Steen My

RO D O 3


30/600

4 1 INTRODUCTON HE EVCAL & HOACC SPNE: MECHANCA AGNO & HEAPY


31/600

: The Problem of Neck Pain

Introduction

his chapter proes bacgroun information about nec pain an

its impact on the geneal popuaion. Moen clnical epiemiology

is con erne ith the istribution natural history an clinica course

of a isease ris an prognosic factors associate ith i the health

nees i prouces an the etermnation of the most effective methos

of reament an management (Sreiner an orman 996) A briefovervie of these mensions as relate to nec pain is provie

Sections are as follos:

prevalence

natural hstory

severity an isabiliy

heath caeseeing

rs factors

onset

prognostic actors

cost

treatment effectiveness

Prevalence

The epiemiology of nec pain in the ault population has been ess

thoroughly investigate than lumbar bac pain but there s still a

easonable amount of literature upon hich to ra Populaion

base sues give the best incation of the rates of a probem in he

community an the nings are ispaye n able 1 Sampling

methos response rates an enitions have varie beteen stuies

an may explain some of the fferences in results onetheess he

surveys generally reveal he common nature of nec pan alhough

e cannot be sure of the exact prevaence rate in the population.

The role that enition of pan site has in altering prevalence gues

is llustrate by one stuy that gave year prevalence of nec pain as

CAP O s


32/600

6 CA ON H CVIA HRAI S MHAA DIAI RA

3 % and nekshoudehigher bak as .5% (Piaet ad Shoue

2003). n a osta surey it is no ossibe to or the aaoia

orgn o these sytos.

Lietie reaee o nek ain was about 70% i two studies Point,

onh ad year reaee range i a uber o studies, betwee

2% and % o the geea ouatio (Tabe .)

Tbe Prevence f neck pn n gener pputn

studesPoint/month 6m-ly* Letime

Reference Count prevaence prevaence prevaence

Hasvold and Johnsen Norway 20%

1993

Makea e a. 199 Finan 41% 7%

Bovm e a 994 Norway 34%

Cote e a 998 Canaa 22% 67%

Lock e a 999 U 21%

Lecerc e a. 999 Fance %

Takaa e a 982 Fnand 17%

Westeng and Jonssen Sweden 12% 18%

1980

Urwn e a 998 U 16%

Pcavet and Schouen eheands 2% 3%

2003

Bassos e a 1999 Span 22%

Linton e a 1998 Sween 4%

Hagen e a 1997a oway 15%

Coe e a 2004 Canada 53% M 21% 31% 69%

six oth or oe year reaene

The annua nidene o nek ain deed as a new eisode durig

a oow-u year in those ree o nek ain at baseine has bee

esiated to be 5% to 95% i three ouatio studies (Leer

l 999; Crot l 200 Coe 200). Athough these studies

eea the oon naure o these a oaits in he generaadut ouaio, hey do ot e us abou ersisene o sytos

seey or what iat ek ai has on eoe' ies


33/600

R AN

Natural hstory

A nubr of studis suggs tha k uba bak an th naura

hstor o nk an is frqun roatd and isodi. n two

ong- foow-us of or 250 atnts with nk ain nar

60% rortd ongoing or rurrnt robs (Ls and Turnr 963

Gor l 987). In hos who had ongoing stos us or haf

rortd h to b oda or sr (Gor l 987) Rtros

i 2% of a gna ouaion sa of nar four thousand

rortd an isodi histor of nk-shoudr-brahia ain (Lawn

969) About onhird of aints wih ra radiuoah ha

rortd a ast on rous isod (Radhakrishnan 99).n a stud o nary sn hundrd ndiduas foowd o a ar

0% rortd nk ain on two oasons (Lr l 999). A

twar foow-u stud ound on % of thos iniay sik-std

for nk a o b anfr whas % rord thss o b

th sa or wors han thy had bn w as air (Kjan

l 200). In a foow-u study of nary ght hundrd indiduas

who rotd nk ain at basin 8% rortd symtoms on ar

at (Hi 200) Ths rorts a suggst that at ast 0% of

thos who rort nk ain w ha a histo o ras and fuur

isods ry siiar to th ras at rord in ongrm studs

of ubar bak ain atints (MKnzi and May 2003).

qua orts of rsisnt and ong-r ain roongd o man

onths ar found aongst thos wth nk an just as in h ubar

bak ain ouation (ab 2). Again h difuy o dtrining

th origi of sos f around th nk-shoudrur bak

rgion aks gurs iis Dnding on whthr th dniionof nk ain s iitd o inus h aag of ths gurs suggsts

btwn 6% and 23% o th adu gnra ouation suff fro

rsistn nk ain o at ast th onths duration

CAR ONE 7


34/600

I CAE OE E CERVA RA SINE MEANIA DIA ERA

be Pevence f pessten neck pn n gene

ppun

ReJerence Count Nek pi Jar> 3 mohs

Adess e l 993 Swede 17%

0% (e-shder e)

Brbeg e l 989 Swede 9%

Begm e . 200 Swede 9%

Pve d She eheds 4%200 6% ek shdes,

hgher b)

Me e 99 d %

H e . 2004 UK 8%*

Ce e l 200 Cd 7%

Gez e l. 200 Swede 18%

Mn 26%

* ersstent an dened as hroni reurren or ontiuous

In oer a thousand indiiduas, just oer ha o whom had nek ain

at baseine 5% deeoed new nek an and 70% had ersistent

reurren or worse nek ain a one year (Cote al. 200) Amogsthose who reorted nek-shouder-higher bak ain ony 6% reored

a nge non-reurren eisode 39% reorted ontinuous ai and

55% reorted reurrent symtoms (Piaet and Shouten 2003). t

is ear that the natura history o nek an s simiar to that o bak

ain and is oen ersisten or reurrent.

Svrity and disability

he as sudy aso reorted on symtom seerity. In those with

ontinuous or reurrent ain (8%) % reorted ths to be seere

but a urher 0% reorted seere eisodes against a bakground o

mid ontnuous an (Piae and Shouten 2003) A mnorit (6%)

reorted artia disabiiy rom work and work eae greaer than

our weeks due o nek symtoms; howeer whe 29% reorted

some imtation o dai iing the majorty (80%) reorted o or

mnma work oss (Paet and Shouten 2003) High disabiity

atributed to nek ain aears to aet he mnority (


35/600

RB F K PAI

Fgue Sevey nd dsby grdng of neck pn

N = 00)

5

�

'. i

oo

Grade � no pain, no disabiityGrad � low inenity ow diabiiy

Grade � hig nnsityow disaiityGrade 3 � ig disabity/modraty imitigGrad � hig diabiity/evrey imiting

Souc: CO et al. 998

Health care-seeking

As wth those who hae ubar bak an, no eeryone wth nek

an seeks heath are. n the etherands, just oer 50% o those

wth nek-shouder-uer bak an had ontat wth a G seas

or hysotherast (Paet and Shouten 2003 n the S, n wo

studes wth a xed ouaton o nek andor bak an, 25% to

% had sought heath are ro a oeentary or onentona

roder (Cote a 2001; Wosko al. 2003. n he UK, 69%

onsuted a heah roessona, osy ther GP or, ess oon

a hysoheras (Lok al. 1999

Cear not eeryone wh nek robes seeks reatent, but beause

o the hgh reaene rae n the genera ouaon, nek an aentseaure ronenty n heath are seres O 6526 atents stng

GPs n nand durng a two-week erod, 27% o those oer the age

o een had usuoskeeta robes (R koa al. 1993. weny

er ent o he had nek an, oared to 18% wth bak an,

whh reresened oer 4% o a GP onsutatons. n a surey o

oer 1700 atents n rary are hYotheray ns n the UK,

22% had nek an (a 2003

Risk factors

Rsk ators are arabes tha are assoated wh a greaer hane

o aqurng the ondton o nterest n ths ase nek an here

are nuerous studes tha hae tred to denty rsk aors that are

A O 19


36/600

0 CHAR O CRVA HRAI S MHAA DIA HRA

assoiated wih nek ain, and seea eiews ae aaiae (Bongers

1; Aiens 1; ingard and Naheso 2000) Studies

tend o eauae idiidua risk atos hsia ad shosoa

work-reaed ators and onwork-reated atos ost studies

address on a ew risk ators, o on one te o rsk ao, ad

do not aount o other tes o risk ators This oeriates the

roe o aiaes eing onsidered and gnores ariaes that are not

nuded in he anasis. Most studies are rosssetiona in nature,

reording rsk ator and ouoe (nek ain at he sae tie his

a reea an assoation etwee the aor and an, ut does not

or a ausa ik Prosete stud desigs are ore ost ad

oaed, u an oe ear estaish a ausa reaions asthe ae oduted i a ohort oowed oer ie

ndiidua ators assoiated with nek ai are eae sex, nreasing

age u to aou 50 when the risk deies, and histor o reious

nek ain As aread noted in the setion on natura histor reious

ek ain is a otent risk ator or urther sos eseia

o ersisten nek ain (Leer 1; Crot 200) os

studies reo higher reaene raes o nek ain i woe tan

en (We 200; Crot 2001; Lee ; Cote 18; akea 11; Hasod and Johsen 1; Adersson

; Weserng andJonsson 180) Seera studes oud the

reaee o nek ain inreases with age at east unti aout 50

to 60 ears o age ater whih sto reorting sees to deie

(Hasod and Johnsen 1; akea 11; Lok 1;

Takaa 182; Andersson 1; Kraer 10) Weak

assoiatons hae een ound etween sokng, oeit, owressure

an hreshods ad nek ain (akea 1 Cote 2000;Andesen 2002)

Coorities hae ee assoiaed wth nek an, nae othe ain

oes suh as headahe (Leer 1), ua ak ain ad

reious nek inuy (Aderse 2002; Cro 2001) u aso

digestie and ardoasuar roes (Coe 2000) Other studes

aso suggest an assoiation etween nek a ad ain in other sites

(We 200 Rekoa 17; Kjean 2001)

Soe studies dented shosoia ators hat are assoated with

nek ain, ut a sudies hae ound no assoiation (Bongers

1; Arens 1; ingard and Naheso 2000)

Pshoogia distress has een assoiated with nek ain (Leer


37/600

RB F K AI

1999 Makla 991 Coft 2001. Bakow-Bgkst

998 fou isk facos ai btw m a wom

mog slmploymt a woy w associa wt cksou sympoms amogst wom moooy a coto a wok

ow ucaioa ll low osho com a ais matial

pato a so associatio w ck pai Makla 199

Cot 2000 Wb 200 Th was o latosip tw

wok sasactio a ck pai u high job satisfacio ha a potc

fct Lcc 999 Hig pci ob mas a ow

socia suppot at wok w associa wi ck pai s

2002 s 2001a. Th lat was a pospcti sty sig

hat ajust fo pysca a iia caacistics a thus haa sog stuy sig is 2001a I a fog pospcti

sy psychosocial factos i ciloo w uimpotat pcos

o ck pai as a ault Viikai-Juta 991

Physical wok acos ha also b show to a a latoshp

th ck pai altoug ot al sts a cosistt i i igs

is 1999. Rws fou aios stis stogy co

la ck pa wih wok i saic postus such as typsts sua

isplay woks a swig mach opatos Gico 1998

Viga a achmso 2000 Hai wok pit wok foc

a ck xio ha associa wih ck pai Maka

99 s 2002. Sal oh stis ha fo a

assocato bw ck xo a ck pai Datgus

988 Kilbo 1986 Igatis 99. S sus look

a t associatio tw sttg a ck pai: fou ou a wak

associaio a th fou o sigifca aiosp is

1999 ow i a stuy with a stog g a positpt assocao was o tw sttig a ck pa a

bw ck xio a ck pai is 00 is was

a pospci sty takg io accou o coouig pyscal

psycosoca a iiual actos.

wo sis ha look spccaly at factos assocat wih

poaps ccal ttba isc isas Ksy 1984

s 1996 Fut ay lifig cigatt smokig a

ig w associat wih t iagosis o sty Klsy

1984. Js 996 fou tat al m i occupatos iolig

pofssioal ig a a la isk of big ospas wi

polaps cical itba sc.

AR O 1


38/600


39/600

R NECK AI

Sval ct coo studs av dtd ms fom ck pa

sto ad comobidts as pogostc facos Hg tal pa ad

ucoa dsabit scos log duato of cu psod pvious

psods o[ ck pa lod -big ad lmitd patit pcta

ios of tatm av pdctd poo outcoms at tlv mos

Kjma et 2002 Od ag (> 40 ad cocomat lo ack

pa av pdctd a poo outcom bot so- ad og-m

ad tuma, log duato ad pvous sto of ck pa av

pdcd poo outcom ogtm Hovg et 2004 I a lag

populato sud a g udd potd ck pa at asl

ad folod fo a a 48% pod coc cut

o cotuous ck pa Hil et 2004 Sgicat bas caactstcs tat pdictd psst ck pa old ag > 4

spcal 4 to 9 g off ok at basl comod ack pa

ad ccg as a gula actvit

Cost

I t Ntlads t toa cost of ck pa 996 as estimated

to b US$686 mllio Bogous et 999 Of ts 23% as

spt o dct mdcal coss, most psca tap as 77%

as absod b soctal omdcal coss Ts compad to a

smad cos of US$4968 billo fo ack pa t ads

991 va Tud et 199

Treatment effectveness

s i lumba back pa a d ag of am vios

a ofd to pas i ck pa s tvos av otappad o affct t udg pvalc o cuc as

um o ssmatc vs av udtak to vaua

t tatmt fcvss of tvos fo ck pa ad t

coclusos a summasd

Evidc dos ot suppot t us of acupucu fo coc ck

pa of ig g-qualt tias v gatv Kjllma et

1999 Wi ad Est 1999 Subsut tals av dmostad

sot-tm cags pa, u oucoms o tt a sam

tatm Ic et 2001, 2002 o ot cca gcal

bt ta placbo W et 2004 Hg-uat studs dmo

statd lack of fct o acto Kjllma et 1999 adlpa

CHA PR O 13


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14 HA O CRVIA & HAI S MEHAIAL DAI & HRAY

Panl 2001) Data gaing th us o ultasoun TENS assag

lctical stiuation an ot lctotapy oaitis o hat

thay is it acing it o conlictng Piahia Panl

200 Koling et al. 2005)

At psnt th is littl scintic vinc to suppot t ctiv

nss o ultiisciplinay biopsychosocia abilitaton pogas

Kajalann et al. 2001)

Sval viws hav povi iit to oat suppot avou

o th sott bnts o obilsation ano anipuation o

so typs o nc pain and/o aacs A et al. 1996 Huwt et

al. 1996 Kan et al 999 Bonot et al. 200 2004) Howv

D abo 1999) consi that th itatu os not onstat

that t bnts o anipulation outwigh th iss tat a nvolv

Rcnt viws Goss et al. 20022004) conclu tat anipulaton

and/o obilsation ha no btt ct than lacbo o contol goups

an w qual whn copa to ach oth but on alon nt

w bncial Howv whn anual thapy was cobn with

xcs sults w supo to contol goups o b o cla bnt

anual thapy it ss ust b cobn with xcs

Sva vws av cont on th ctivnss o xciss o

nc pain Kjllan et al. 1999 SagBahat 2003). Th Pilalphia

Panl on EvincBas Clnical Pactc Guins conclu

tat taputic xcis was th only ntvnton wt cinicaly

potant bnts ativ to a contol Plalpia Panl 2001)

Wn xcis as bn copa to obiisation o anpulation

plus xcis bot goups show siila ipovnts Goss et

al 2004) This last viw "shows h i does no mer wha ind

of pssive remen one offers, i is wh he pien does h rely

mers ailis-Gagnon an ppan 2004)

Hoving et al. 2001) inti an xan twtyv viws

o which twlv w systatic but all ths w o t 1990s

Conclusions lac agnt about obilisaton acuunctu an

ug thapy but ag that th vinc was inconcusiv on t

ctivnss o anipuaton an taction

Ths b suay o t litatu spit its iitations wou

suggst ctain concusions about th anagnt o nc pain that

concu wit anagnt giins about low bac pa. Th ang


41/600

TH R F NCK AI

of pass thapis offd to ck pai pats may pod som

imtd shot-m pai i at bs but most ha faild to do

sta ay usu log o sottm b Fo a wd ag

of passi tapis stll big dispsd by cicias o a gula

bass th s scat suppoi dc

Fo mo aci amts h idc is mo posit cs

appa to b fc Maual tapy may b ffct w

combid wih cis bu has dmostatd a o poo out

coms w compad to cs alo

Conclusions

Ou dsadig o th poblm of ck pai must tfo b

gidd by ca ifutabl tts

Nck pai is so commo it may b said o b oma k

commo cod Rssac to th mdicalisatio of a omal

pic shoud b aid to a sf-maagmt appoach

wic psoa sposbity s gdd

• T cous of ck pa is fquty ll of pisods psistcla-ups cucs ad choic I is impota to mmb

ths th cliica cot maagmt ms aim a log

tm bs o smply shot-m symptomatic li

May pop with ck pai maag dpdty ad do o

sk halh ca

Maagm shold b dictd a yig o dc dsabiy

ad nd [o ca-skig hs goup by coagg a slf

a ad copig atitud

Nck pai is o aways a cab disod but fo may a

liog hath pobm uiig o-gog maagmt No

itto as b show o alt h dlyig palc

icidc o cc ats Cosquly maagmt

must ad should always off mods of slmaagm ad

psoa sposibiliy to th pati

Passi modaliis appa to a o o i h maagmt ock pa h idc faos aci ittos pmaly

cis

CAR ON 15


42/600

16 I CHAPE ONE TH CVAL & TH-A SINE: MAIA DAGN & AY

Ge te epeology of eck pa the eece about tee

tos a he roe tat psycosoca factors ae affectg croc

sabty aageet peates shoul be cear Pates ust

be ecourage o ao est a reur to oa ac cesoul atept o ecrease axety about eck pa affect attues

a beefs aout pa a shoul aress selfaagee of what

ay be a o-gog or recurre pole. Patets ust be foe

that er acte partcpao s ta esorg full fucto trough

se-aagee exercse a actt Patets soul be proe

wth he eas y wch hey ca affect sypos a tus ga

soe corol oe ter proble

therapeutc ecouter ees to equp e ual wth log-er

selaageet sraeges whc ay be ee ore porat tha

short-er easures o syptoatc poee o o oewse

a treat pates wt sot-er passe oaltes or apulato

but ot eup he wt orato a strateges or sefaage

e s -cocee a s o te patets bes eres If a

coto s ey coo persstet ofte epsoc a ressat

o easy reey pates us be fully epowere to eal wh these

probles a opa a realstc fasho s clcas we shoue offeg ts epoweret o ou patets.


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: Pain and Connectve TissuePropertes

Introduction

Pi i ly the prime coce of the ptiet h, ome me

of dertdi d iterpreti pi mportt hi chpter

reiew certi pect of pi tht re reet to the cericl pie.

A diticto mde betwee ociceptio d the pi eperiece

commo orce of pi i the ceic pie re idetie d; dfferet

type of pi re cowleded, ch omtic rdiclr, icerl d

cet, well ocl d refeed pi, d p of mechicl

or chemcl orii he ditictio betwee thee two mechim of

pi i mportt determit of the ppropritee of mechicl

therpy (McKeze 1981, 1990). I mcloelet problem

commo ce of ifmmtio follow oft tie trm ch

dr whplh ijy o the heli proce of ilmmto

repi d remodelli i brely reiewed. Some coidetio i lo

ie to the ie of chroic pi .

Sectio thi chpter re follow

occepio d pi

oce of ec p d cericl rdicopthy

type of p

•

•

omtc pi

dicl pi

combied tte

cetrl pi

icerl pi

chet pi

ctitio of ociceptor

mechic occeptio

• cemicl occeptio

trm ce of pi

ditiih chemicl d mechic pi

CAER w 7


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8 CAER TE CERVA & ORA E MEAAL AGNO & RAY

tissue repir process

• inmmton

• issue repr

• remoeng

• fiue to remoe repir issue

• chronc pin sttes

Nociception and pain

The mens by hch inoton concerning tissue mge iseperience n trnsmite to the corte is ee nocception.

his hs sever components (Bogu 993 Ge 2002):

• the etection of issue mge (trnsucion

• the rnsmssion of nocicepive informtion ong peiphe

nerves

• its rnsmisson up he spin cor

moution of he nociceptive signs by escenng pthysfrom hgher centres in the cen nevous system.

The nerve enings tht etect pin re not speciise receptors.

Normy they re nvove t other sensory functons but s the

smuus becomes noious he ge response o e recepors

crosses the thresho fom norm mechnc or ther sension

n trggers the nocicepive process (Bogu 993. Afte tissue

mge is etece this informion is rnsmite by y o the

pephe n centr nervous system o the coe. oeveren route he nocicepive messge is moute in his y te centr

nervous system cn eert n inhibitory or ecitory inuence on

he nociceptive inpu (Wright 00) Thus he cssc cncept

o pin being srightfor eecion of specic issue ge

s oumoe given the current unersnng of pin Especiy

ih ptiens ho hve chronic pin the ctors th nfuence the

cinc presenttion re more thn smpe noccepion (Unru n

enrisson 2002).

Pin hs been ene s "n unpesnt senso nd eotion expe

rience ssocited wit ctu or potenti tissue dge, or described

in ters o suc dge (Mesey n Bogu 994. is muc-


45/600

PAN AND CONNV PO

qote an iey accepte eni ion recognises hat the experience

of pan is a cotca phenomenon an s inence by afectve an

cognitive acors as e as sensory ones (Bog 993 nrh an

enisson 2002 ; ohnson 1 997

It s mportat to recognise tha the experience of pan invoves

patients emotiona an cogitive reacions o the pocess o nocicepion.

Patiens anxieties fears an beiefs may songy etemine her

esponse to nry pain an teatment Fear of pain an einjy may

ea to avoiance of activies tha it s hogh o more ham It

may ea them to estict their actions an movements an to ith

ra from their norma ifesye An exaggeate fea o pain cope ih a hyper-vigiance to every mnor iscomot can ea the paten

nto a perpeta circe o isse epeion isabity an pesisten

pain (Vaeye a nton 000 Sch ac of nersaning of hei

conion cases inapproprate action in the ace of pan an proces

eeings of imte abity o conro o aect he coniton

We can star to aress these actos by provng patients h a

thorogh nersaning of the probem an ecaing them in the

appopriate se o aciviy an execise to egain ncion an ece

pain. Faiitaing paiens' conro over heir pobem encoaging

actve copng srategies an heping them confront their fear of pan

sho a be pat of managemen Stategies base pon ecaton

an patien activty ae imporant as a means of areing paient

esponses o a painf coniion as e as the coniton se.

Souces of neck pain and cevical adcuopathy

Any srcre that s nnervae is a poeni soce o sympoms

In an aron the cervica spine the oing strcres meet his

citeria: msces igaments zygapophysea oins inervereba iscs

anterior an poseior ongtna igaments he atanooccpita an

atanoaxia jo ints an their igaments he boo vesses an he ra

mater (Bog 1 988 00b Mcain 1 99 Mene l 992

Groen 1 988 1990 Posero stctes receive innevation from

he orsa am o the cervca spne nerves hie the venta rami

an the sinverebra neves innervate anteo stctes (Bog

1982 2002b. Regaring the inervertebra scs no nerves have

been fon in the nces pposs an nea eements ere mos

prevaen n the poseroaea region of he isc an penerate to the

CHAR Two 9


46/600

2 CHAR Tw H CRVA & HORA N: MHAN A IAGNOS S & HRA

ouer thir of the nnuus brosus (Mene al 1 992 Bogu al

1988 The sinuvertebr nerves hve been escibe s inneving

the isc t their eve o enry n the isc bove (Bogu 988

hoever more vribe ptterns hve so been emonste, ith

the nerve scenng or escening up to to segments (Groen al

1990 Nerves nnervting the ur mter hve been foun o rmify

over up to eght segments ith consierbe overp beteen jcent

nerves (Groen al. 19 88. This istribution of innervting nerves pro

vies n ntomic subsrte or n unerstning o etr-segmen

y reerre pin ptterns. ervic ricuopthy is the pouc of

pthoogy fectng the cervc nerve root or os root gngion

n is consiere in moe eti in the net section.

Types of pain

One propose pn cssiction system hs suggeste the fooing

bro cegories of pin (Woof al 1998:

tissue injury pn

nervous system injury pin

rnsient pn hch is of br ef ution n itt e conse

quence.

Tssue injury pin retes to somtic structures his nervous sysem

injury pn incues neurogeni or ricur s e s pin genete

ithin the cent nervous sysem An empe of trnsient pin is

tht prouce in postur synrome he othe source of pin th

occsiony must be consiere in he iffeent ignoss is

visce pin from ogns (Bogu 1 993

Table 1 Basic pain types

Pain type

Somatic pan

Radicular pai

Combned states

Cera pan

Vscera pa

Structurs volved

Musculoskelea tissue

Nerve roo/dorsa roo gangion

Equals boh somac and radicular pai

Ceral nervous syse

Viscera orgas


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PAIN AD COV TSSUE PRORI

mtic pin

Somtic structures incue the inervetebr scs nteior n

posteior ongitn gmens zygpophyse oint cpsues

musces n so on. Ony pin th oigintes om cutneous issue

is e ocise to he re o tisse mge; pin tht sems om

eep somtic stuctures is reee pin to greer or esse exten

Bog 1 993) The eeper the strcture the more icut i s o

ocise e pn soce Ths most muscuoseet pn s eerre

pn to vrying egee The bin is simpy e o pn signs

emnng rom hose stctres tt e suppie by cerin segment

o te spin cor The most pusbe mechnsm o ths is non s

convegence eurons n the cenr nervos sysem receive eentsrom structres n the cevic spne n the shoue gire ces

n upper mb. he brin is unbe to etermine he ue soce o

nocceptor signs rom the shre neon Over n Meitch

99 1 ; Bogu 1 997)

Reere pin smpy reects the c o ocsing inormion vibe

ith noccepto civiy om eep stuctes he y o somtic

reerre pin is eep n cing in uity vge n hr to ocise

Eperimens in te mb spine emonstre ht he stronger

the noious stmuus, te urther the pn spes on he imb

Kegren 939 nmn n Sner 1947 Mooney n Robetson

19 76) Simir expements hve not been conucte etve to he

cervic spine

Stmton o cevic musces igments ntervertebr scs n

zygpopyse oints h noxious njections hve prouce symptoms

reerre to te e shouer gire scpur nterior n poseriorchest n ppe imb epening on hich eves e simue

Kegren 1939 Feinstein a 19 54 ; Dye al 99 o

1959 Scehs al 1996 Grubb n Key 2) Pterns o

reere pin re vey simr beteen i erent sructures n i is not

possbe to use ptes o pn ee to me ignostic ecisions

Figures 2 1 , 2 2 ). ppe n micervic segmens ten o eer to

the occiput nec n upper soue; oer cervc segments ree

to e soer scpu n uppe rm Grubb n Key 2;

Scehs al 1 996 Dyer al. 1 99) Pinu inervertebr scs

possiby e more iey to reer to he upper rm n ntero ches

The e o heche o cevicogenic origin s scsse more

y in pe 4

CHAR Two [2


48/600

22 CHAR Two E CERVAL & HORA : MHAA AGNOSS & HERAY

Fig ure 21 Paers of referred pai produced y simulaig

cervical zyg apophyseal jois ormal idivduals

Source: Adapted [rom Dye l 1990 ey[ss l 994 with emission

Fig ure 22 Paerns of referred pai produced y discog raphy

a sympomaic levels

C 2-C 3 C 3 C C-C5

C5C 6 C 6 C7Soe e om Slipm 25 d Gub ad Kell 2


49/600

AN AND CONN V TS U IS

dicur pi

An understanding of radicular pain s based lagely on its presenta

ion in the lumbar regon Neve oot compession by itself does no

cause pan only oss of neurologcal function however, radiculopathy

can be associated wth pain and other signs and symptoms (Bogduk

22b Kramer 99) he constellation of signs and symptoms tha

may ndcate neurogenic pain include the folowng although no all

may be present

• adcular pain patern

reduction or loss of sensatioparaesthesanumbness in distal

end o dermatomeweakness or loss of power in specic muscles

reduction or loss of specc reexes.

Radicular or neurogenc pain s poduced when the neve root or

dorsa roo ganglia are nvoved n sympom production Ths is

the product of pressure on nerve roots that are aready inlamed or

iriated in some way, no on normal neve roots Alhough sudden

onset of adculopahy does occur, experimentaly tenson or ressurehave only reproduced adicular ain on sensiised abnormal umbar

nerve roots (Smyth and Wright 958 Kuslich al 99)

Radicua pain is difeent in qualiy rom somatic pain and is

frequenty associated wth ohe abnomalites of nerve conducion ,

such as weakness o numbness, and abnomal tenson tests (Bogduk

22b) . Radcular pain is severe, ancinating or shooting in quality,

felt aong a narrow strip and thus different in qualiy from he vague ,

dull achng associated wh somaticreferred an Al l nerve roo painwill be fet n te arm it is always eferred pain Often the am pain

is worse han any

the cervical and thoracic spine - mechanical diag., therapy 2nd ed. [2 vols] - r. mckenzie, s. may...

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