Asymmetrie der Kopfgelenke

Before initiating manipulative therapy in the region of the atlanto-occiptal joints in patients with functional disorders of the spinal column, biplanar X-ray examination is necessary whereby asymmetries are frequently found in the region of the cervical spine. We sought to answer the question of whether such asymmetries are only found in “ill patients” or whether they are also found in healthy subjects. We evaluated 212 whole spinal column X-rays of the atlanto-occipital joints and cervical spine of test subjects with no subjective complaints. The variability of the asymmetric alignment of the affected joint pairs was large. Symmetry in the positions of the occiput, atlas, and axis could only be observed in 6% of the cases. Laterality of the atlas and axis toward the left in relation to the skull base was found with conspicuous frequency. If clinical symptoms accompany functional disturbance of the atlanto-occipital joints, this radiologic-anatomic asymmetry is significant for planning appropriate manual therapy. Further statistical analysis of the individual measurements and correlations revealed high significance for ponticulus posticus with a disorder of the atlantal arch. If ponticulus posticus is observed, the incidence of symmetric atlas position is significantly high.     

Force transmission between thoracic and cervical segments of the spine during prone-lying high-velocity low-amplitude spinal manipulation: A proof of principle for the concept of regional interdependence

BackgroundRegional interdependence is conceptually based on observations that applying manual therapy to a remote anatomical region has an effect in the area of the patient's primary complaint. The current model for regional interdependence depends on force transmissibility within the body. This investigation sought to determine transmissibility between forces applied to the thoracic spine during prone-lying high-velocity low-amplitude spinal manipulative therapy and the cervical spine.MethodsA chiropractic treatment table was modified to allow (or disallow) translation of the headrest in the caudal-cephalad direction when unlocked (or locked). Prone-lying high-velocity low-amplitude spinal manipulative therapy was applied to the thoracic region of 9 healthy participants with the headrest in both configurations. Head and thorax kinematics and kinetics were measured at interfaces between participant and the external environment, which included the clinician's hands. Compressive forces at the cervicothoracic junction and angular kinematics of the cervical spine were derived. Ratios between the clinician-applied forces (input) and the cervical compressive force (output) were also determined.FindingsThe cervical spine extended during all high-velocity low-amplitude spinal manipulative therapy trials. Force input-to-output ratios exceeded 1 for high-velocity low-amplitude spinal manipulative therapy trials performed with the headrest in the locked configuration, which was greater than ratios for the unlocked configuration.InterpretationForces imparted to thoracic spine during high-velocity low-amplitude spinal manipulative therapy were transmitted to the cervical spine, which provided a precursor for the regional interdependence model for manual therapy. Friction between the participant's face and the treatment table's head rest likely amplified cervical compressive forces.     

The Prevalence of Facet Joint-Related Chronic Neck Pain in Postsurgical and Nonpostsurgical Patients: A Comparative Evaluation

Background: Facet (zygapophysial) joints may be clinically important sources of chronic cervical spinal pain. Previous studies have demonstrated the value and validity of controlled, comparative local anesthetic blocks in the diagnosis of facet joint pain, and reported an overall prevalence of 36% to 67% facet joint involvement in cervical spinal pain. The reports of lumbar facet joint‐involvement in postsurgery syndrome have been shown to be highly variable with prevalence ranging from 8% to 32%. To date, however, the prevalence of postsurgical facet joint‐related pain in the cervical spine has not been evaluated. In light of this, the present retrospective study was conducted to assess and compare the prevalence of chronic postsurgical facet joint cervical spinal pain to nonsurgical, chronic cervical facet joint pain. Methods: Patients presenting with chronic neck pain were studied. The procedures were performed by a single physician in an interventional pain management ambulatory surgery center. The prevalence of cervical facet joint pain in postsurgical patients was assessed and compared to nonsurgical patients. Results: A total of 251 patients (45 postsurgery vs. 206 nonsurgical patients) with chronic persistent neck pain were evaluated using controlled, comparative local anesthetic blocks in accordance with IASP criteria. The prevalence of the cervical facet joint pain and false‐positive rate of single blocks in postsurgical patients were 36% and 50% compared with 39% and 43% in nonsurgical patients. Conclusions: Cervical facet joints are clinically important pain generators in a significant proportion of patients with chronic persistent neck pain after surgical intervention(s). The prevalence of cervical facet joint pain was similar in both postsurgical and nonsurgical patients. ?     

Facet joint pain and the role of neural blockade in its management

Chronic spinal pain is a common medical problem with serious financial and social consequences. Among the various structures with potential for producing pain in the spine, facet joints as sources of chronic spinal pain have attracted considerable attention and controversy. Significant progress has been made in precision diagnosis of spinal pain with neural blockade, in the face of less than optimal diagnostic information offered by imaging and neurophysiologic studies. Research into the role of facet joints in spinal pain has shown that cervical facet joints are the cause of chronic neck pain in 54% to 60% of patients, whereas lumbar facet joints cause pain in 15% to 40% of patients with chronic low back pain. Local anesthetic blocks of medial branches have proven to be a reliable diagnostic test; they are target-specific when used appropriately with control blocks, either with two local anesthetics with different durations of action or with the addition of an inactive placebo injection. The literature is replete with reports on uncontrolled studies, case reports, and documentation from a few controlled studies, all of which offer supporting information on the rationale and effectiveness of facet blocks and neurotomy. Facet joint injections and medial branch blocks are considered to be of equal value. Lumbar intra-articular steroid injections have been proven effective to a certain extent, but evidence indicates that cervical intra-articular steroids are ineffective. The role of repeat medial branch blocks is not known. Radiofrequency neurotomy remains the only practical and validated treatment for cervical facet joint pain; however, its role in management of either lumbar or thoracic facet joint pain awaits validation.     

The effect of chiropractic care for a 30-year-old male with advanced ankylosing spondylitis: a time series case report

BACKGROUND: Manipulative treatment for ankylosing spondylitis is a controversial subject, and no literature on using this therapy for advanced cases with fusion of the spine could be found. OBJECTIVE: To discuss the case presentation of a patient with advanced ankylosing spondylitis who was treated with chiropractic manipulation and mobilization.Clinical features The patient was a 30-year-old Asian male who was first diagnosed with ankylosing spondylitis at age 12. Despite medical intervention, a series of exacerbations had fused his sacroiliac joints and the facet joints in his lumbar and cervical spine. He presented with local moderate-to-severe pain in his low back and neck and lack of mobility.Intervention and outcome The patient was treated with grade 5 manipulation of his thoracic spine and grade 3 mobilization of his lumbar and cervical spine, along with physical therapy and stretches for a period of 12 weeks. He reported some improvement of his condition as measured by the SF-36 Health Survey and several measures of spinal flexibility. CONCLUSIONS: This case shows that even advanced cases of ankylosing spondylitis may show a favorable response to chiropractic manipulative therapy.     

MULTIDISCIPLINARY PAIN ABSTRACTS: 50

Degenerative disease of the spine is one of the most common clinical entities and affects the intervertebral discs, including opposing vertebral endplates, the intervertebral posterior joints and the ligaments. The most severe primary spinal degenerative changes are found in the lower cervical and lumbar spine regions. The spine contains three different types of joints, each of which presents its own pattern of degenerative disease: cartilaginous joints, synovial joints, and fibrous joints. With regard to radicular pain, root compression alone does not fully account for root pain following disc-root conflict, but it is, nevertheless, considered to be the main cause of pain. The authors pointed out that the origin of pain is multi-factorial and that inflammation probably predominates over merely mechanical mechanisms. They also considered whether vertebral arthrosis can be construed as the body's decision to favor the spine's static function over its dynamic role when joint "hypermobility" linked to chronic load in old age could cause severe structural damage to the bony vertebral structures.     

Manipulation of the cervical spine

In New Zealand, a new approach to manual therapy of the cervical spine has integrated physiotherapy and osteopathy techniques. The combination of the philosophies of these two professions has added a new dimension to the management of cervical spine pain. Emphasis is placed on issues of safety, such as the degree of cervical rotation and comfort for both the patient and the therapist. This is combined with biomechanical considerations, which have made the teaching and learning of these manipulative techniques less complicated and easily progressed from palpation to mobilization and onto manipulation. Appropriate patient screening and selection identified through thorough subjective and objective assessments are important aspects of this approach and reflective interpretation of all clinical findings is essential. The refinement of cervical joint positioning and an increased anatomical awareness have led to the utilization of new upper cervical high-velocity thrust techniques. Consequently, it is envisaged that an increase in the safety and specificity of cervical manipulative techniques is achieved.     

A possible cervical cause of low back pain: pelvic distortion

Objective: to discuss the diagnosis and treatment of pelvic distortion related to cervical spine dysfunction in a patient with low back pain, as well as presenting a theoretical etiology.Clinical features: pelvic distortion is a disorder in which the ilia become counter-rotated on the sacrum. Our clinical experience suggests that it can arise from dysfunction in the cervical spine. It can produce low back pain, as occurred in the presented case. The sacroiliac (SI) joint is often determined to be the primary pain generator, although there may or may not be joint dysfunction detected in this joint. In the presented case the primary pain generator was initially felt to be the T12–L1 joint, as well as trigger points in the iliocostalis muscle. When the pain returned, and normal findings were noted in these structures, the patient was examined for the presence of pelvic distortion. This was found, as was painful joint dysfunction in the cervical spine. It was suspected that the pelvic distortion may have occurred secondary to cervical joint dysfunction.Intervention and outcome: treatment that was limited to manipulative therapy to the cervical spine successfully relieved the low back pain in this case.Conclusion: pelvic distortion secondary to cervical joint dysfunction may be a common cause of low back pain. Further research is needed to identify the prevalence, etiology, mechanism and ideal treatment of pelvic distortion.     

Cervicogenic headache: Anatomic basis and pathophysiologic mechanisms

Cervicogenic headache is pain perceived in the head but referred from a primary source in the cervical spine. The physiologic basis for this pain is convergence between trigeminal afferents and afferents from the upper three cervical spinal nerves. The possible sources of cervicogenic headache lie in the structures innervated by the C1 to C3 spinal nerves, and include the upper cervical synovial joints, the upper cervical muscles, the C2-3 disc, the vertebral and internal carotid arteries, and the dura mater of the upper spinal cord and posterior cranial fossa. Experiments in normal volunteers have established that the cervical muscles and joints can be sources of headache.     

Anterolateral percutaneous vertebroplasty at C2 for lung cancer metastasis and upper cervical facet joint block

Percutaneous vertebroplasty (PVP) of the axis (C2) is less aggressive than any surgical stabilizing procedure for the upper cervical spine, and it does not restrict the mobility of the upper cervical joints. Disruption of the weight-bearing unit of the second cervical (C2) vertebral body causes excessive load at the relatively small adjacent upper cervical joints. Upper cervical joint block before or after PVP at the C2 level has not been reported thus far. A 67-year-old man was referred to a pain clinic with a 6-month history of increasing neck pain without focal neurologic symptoms. Studies revealed a compression fracture of the C2 vertebral body and invasion of the adjacent soft tissue. To treat the mechanical component of the symptoms, anterolateral PVP at C2 was successfully performed, but the residual suboccipital headache was alleviated only after upper cervical joint block was performed. Thus, upper cervical joint block can be performed to treat the residual suboccipital headache after PVP at C2.     

Recurrent neck pain patients exhibit altered joint motion pattern during cervical flexion and extension movements

BackgroundImpaired sensorimotor ability has been demonstrated in recurrent neck pain patients. It is however not clear if cervical joint motion and pressure pain sensitivity in recurrent neck pain patients are different from asymptomatic controls.MethodsCervical flexion and extension motions were examined by video-fluoroscopy and pressure pain thresholds were assessed bilaterally over C2/C3, C5/C6 facet joints and right tibialis anterior in eighteen recurrent neck pain patients and eighteen healthy subjects. Individual joint motion was analyzed by dividing fluoroscopic videos into 10 epochs. The motion opposite to the primary direction (anti-directional motion) and motion along with the primary direction (pro-directional motion) of each joint were extracted across epochs. Total joint motion was the sum of anti-directional and pro-directional motions. Joint motion variability was represented by the variance of joint motions across epochs.FindingsCompared to controls, recurrent neck pain patients showed: 1) decreased anti-directional motion at C2/C3 and C3/C4 (P < 0.05) and increased anti-directional motion at C5/C6 and C6/C7 (P < 0.05) during extension motion. 2) Increased overall anti-direction motion during flexion motion (P < 0.05). 3) Lower joint motion variability at C3/C4 during extension motion (P < 0.05).InterpretationRecurrent neck pain patients showed a redistribution of anti-directional motion between the middle cervical spine and the lower cervical spine during cervical extension and increased overall anti-directional motion during cervical flexion compared with healthy controls. The anti-directional motion was more sensitive to neck pain compared to other cervical joint motion parameters in the present study.     

Possible manifestation of temporomandibular joint dysfunction on chiropractic cervical X-ray studies

OBJECTIVE: Our purpose was to show that biomechanical alterations toward and away from normal on x-ray studies may be the result of changes in temporomandibular joint dysfunction and to discuss possible neurologic explanations for this phenomenon. CLINICAL FEATURES: Two patients are discussed; the first had migraine headache symptoms, and the second had chronic hypomobility of mandibular opening, dizziness, headache, and neck pain and stiffness. In both patients mensuration changes in different types of cervical x-ray studies were noted in conjunction with exacerbation of, and elimination of, temporomandibular joint dysfunction. INTERVENTION: Comanagement of these cases was done with dental professionals. Chiropractic treatment included vectored/linear, upper cervical, high-velocity, low-amplitude chiropractic manipulation of the atlas vertebra, diversified manipulation, myofascial therapy, stretch and spray procedures, and soft tissue manual techniques. CONCLUSION: Temporomandibular joint dysfunction may cause cervical muscular and spinal biomechanical changes that may become visible and change on x-ray examination. Further investigation into this phenomenon is recommended.     

Clinical presentation and manual therapy for upper quadrant musculoskeletal conditions

In recent years, increased knowledge of the pathogenesis of upper quadrant pain syndromes has translated to better management strategies. Recent studies have demonstrated evidence of peripheral and central sensitization mechanisms in different local pain syndromes of the upper quadrant such as idiopathic neck pain, lateral epicondylalgia, whiplash-associated disorders, shoulder impingement, and carpal tunnel syndrome. Therefore, a treatment-based classification approach where subjects receive matched interventions has been developed and, it has been found that these patients experience better outcomes than those receiving non-matched interventions. There is evidence suggesting that the cervical and thoracic spine is involved in upper quadrant pain. Spinal manipulation has been found to be effective for patients with elbow pain, neck pain, or cervicobrachial pain. Additionally, it is known that spinal manipulative therapy exerts neurophysiological effects that can activate pain modulation mechanisms. This paper exposes some manual therapies for upper quadrant pain syndromes, based on a nociceptive pain rationale for modulating central nervous system including trigger point therapy, dry needling, mobilization or manipulation, and cognitive pain approaches.     

Association of Spinal Manipulative Therapy With Changes in Cervical Motion Segment Interactions in Patients With Neck Pain: An Observational Study With Matched Asymptomatic Controls

ObjectiveThe objectives of this study were to determine (1) if maximal intervertebral range of motion (IV-RoMmax) and laxity interactions exist in the cervical spine during flexion, (2) if there are differences in IV-RoMmax or laxity parameters between baseline and follow-up in both patients with neck pain and asymptomatic controls, and (3) if there is an effect on IV-RoMmax/laxity relationships in patients with neck pain after spinal manipulative therapy.MethodsTwenty-nine patients with subacute or chronic neck pain and 33 asymptomatic controls were imaged during flexion and extension, pre and post a course of cervical chiropractic manipulation (patient group only), using a standardized quantitative fluoroscopy acquisition protocol.ResultsSignificant correlations between IV-RoMs were found in both neck pain and neck pain–free populations at baseline and follow-up. Positive relationships were found between C2-C3 and C3-C4 and C4-C5 and C5-C6 IV-RoM in both populations. A negative correlation was found in the patient group at baseline between C1-C2 and C5-C6, but not at follow-up. Significant relationships were also found for segmental laxity, with a negative correlation found at C1-C2 and C5-C6 in the patient group only and at baseline only.ConclusionDistinct relationships were found between both intraregional IV-RoM and laxity, many of which were present in both groups at baseline and follow-up, suggestive of normal kinematic behaviors. Changes in correlations unique to the patient group may be indicative of a change in regional kinematics resulting from the manipulation intervention. Spinal manipulative therapy may have a therapeutic effect by influencing cervical kinematics at the regional level.     

Manipulative practice in the cervical spine: a survey of IFOMPT member countries

The International Federation of Orthopaedic Manipulative Physical Therapists (IFOMPT) aims to achieve worldwide promotion of excellence and unity in clinical and academic standards for manual and musculoskeletal physical therapists. To this end, IFOMPT has sponsored several conference panel sessions and a survey of Member Organizations (MOs) and Registered Interest Groups (RIGs) regarding current cervical spine manipulation and pre-manipulative screening practice in each country. The purpose of this study was to determine common elements of cervical spine manipulative practice and pre-manipulative screening between countries. In late 2007, a questionnaire investigating recommended pre-manipulative screening protocol/guideline use, informed consent regarding risks, screening procedures, and treatment/manipulation technique was sent to all twenty MOs and five RIGs. The response rate was 88%. The main findings of the survey included: 77% of respondent organizations use pre-manipulative guidelines, with Australian guidelines the most frequently adopted internationally (36%); recommendations concerning the provision of information about the possibility of serious adverse events is not standard practice in all countries (50%); positional tests for vertebrobasilar insufficiency are used by all respondent organizations; craniovertebral ligament testing is sometimes taught as a pre-manipulative screening tool (36%); the use of upper cervical spine manipulation has declined in some countries (41%); and of the respondent organizations that continue to teach upper cervical manipulation, most (70%) minimize the rotation component. The findings of this research will inform an IFOMPT international standard for screening the cervical region prior to orthopaedic manual therapy intervention. The development of an IFOMPT endorsed document will be of assistance to manual therapy clinicians worldwide in safely managing disorders of the cervical spine.     

Screening of patients suitable for diagnostic cervical facet joint blocks--a role for physiotherapists

The cervical facet joint is a prevalent source of pain in patients with chronic cervical spine pain. Patients with persistent, disabling neck pain, are increasingly being referred for diagnostic facet joint blocks, with the aim of assessing their suitability for interventional procedures such as radiofrequency neurotomy (RFN). A positive response to the block is an indicator of more substantive benefits from RFN. Physiotherapists and medical practitioners are challenged to make appropriate referrals for diagnostic facet joint blocks. This lack of selection contributes to lengthy wait-lists, unnecessary invasive procedures for those who have a negative response and significant costs to the health care system. Physiotherapists use manual examination to identify the facet joint as the primary source of a patient's pain but its diagnostic accuracy and reliability is variable. It is reasoned that a combination of findings of a physical, manual and psychological assessment may better indicate that a patient will respond positively or negatively to a diagnostic facet joint block. Clinical prediction guides (CPG) allow practitioners to use the results of the patient history, self-report measures and physical examination toward optimal diagnostic and therapeutic decisions. It is proposed that the development and validation of a CPG may aid in the appropriate selection of patients for this diagnostic procedure.     

The validation of the diagnosis "joint dysfunction" in the synovial joints of the cervical spine

One hundred patients suffering from cervical spine involvement were examined using procedures developed by the author over a period of many years. The cases were analyzed on the basis of incidence of sex and age, duration of symptoms, role of injury, analysis of radiographic examination and assessment of manipulative treatment. Of the 100 patients, 83 underwent manipulative therapy. Thirty percent of those treated reported cessation of symptoms, and another 34% felt they had markedly improved. It is felt that such information helps to validate the presence of joint dysfunction as a manipulable condition.     

Ultrasound-guided facet joint injections in the middle to lower cervical spine: a CT-controlled sonoanatomic study

OBJECTIVES: The aim of this study was to investigate the efficacy of ultrasound as a guiding tool for simulated cervical facet joint injections in cadavers. METHODS: A total of 40 ultrasound examinations at 5 levels (C6-7 to C2-3) were performed on 4 embalmed cadavers. The zygapophyseal joints were located with ultrasound. First, the transverse processes of C6 and C7 were established and the facet joint of C6-7 was demonstrated. The midpoint of this joint space, defined as the middle of its cranio-caudal extension on its lateral surface, was taken as a reference point. Ipsilateral distances (A, B, C, and D) between this point and each one of the 4 facet joints of the cervical spine up to the facet joints C2-3 were then computed. Subsequently, coronal computed tomography (CT) scans were taken to verify these distances. In a second experiment, a spinal needle was advanced under ultrasound guidance to the zygapophyseal joints from C2-3 to C6-7 on both sides of 1 cadaver. The exact placement of the needle tips was again verified by CT. RESULTS: In 4 attempts, a depiction of the joint space was not possible. Ultrasound and CT provided the same mean measurements of 1.2+/-0.2 cm, 2.0+/-0.3 cm, 3.0+/-0.2, and 4.0+/-0.5 cm for distances A, B, C, and D, respectively. All 10 needle tips were located in the joint space during simulated facet joint injections, as also verified by CT. DISCUSSION: This preclinical study suggests that ultrasound is a useful guiding tool for facet joint injections in the cervical spine.