Rehabilitation of Neck Pain and Myofascial Pain Syndrome

Rehabilitation of Neck Pain and Myofascial Pain Syndrome 復健醫學部 楚恆毅醫師

Objectives of this lecture l To have a basic understanding of the following conditions: cervical strain/sprain, cervical radiculopathy and myofasical pain dysfunction syndrome in terms of clinical presentations, physical examinations and principle of treatment from a rehabilitative perspective l Origins of pain/discomfort in neck region: bone, soft tissues, vessels, nerves and so forth

Introduction and epidemiology l l l Cervical axial pain: pain in all or part of a corridor extending from the lower occipital region down to the superior interscapular region Cervical radicular pain: pain involving the shoulder girdle and distally, in the upper limb General prevalence from 9 -18% Increases with age Radiculopathy: Annual incidence of 83. 2/10000 and with peaks at 50 -54 years of age for radiculopathy

l l l 7 vertebrae and 8 roots C 0 -1: 10° of flexion and 25° of extension C 1 -2: responsible for 40 -50% off all cervical axial rotation; 45° in all direction

Definition of Cervical strain and sprains Strain: a musculo-tendinous injury produced by an overload injury due to excessive forces imposed on the cervical spines l Sprain: overstretching or tearing injuries of spinal ligaments l grading l

Epidemiology of Cervical strain and sprains 85% of neck pain results from acute, repetitive or chronic injuries l Most common cause of neck pain in noncatastrophic sports injuries l

Pathophysiology of Cervical strain and sprains Acceleration-deceleration injuries l Partial/complete muscle tears and hemorrhage l Anterior longitudinal ligament l Disc injury l

The most common lesions affecting the cervical spine following whiplash injury

Diagnosis of Cervical strain and sprains l l l l Symptoms: pain, soft tissue swelling, regional muscle spasm, LROM Thorough history and physical examination: Spurling’s test Headaches? aggravating factors Range of motion Neurological signs Plain radiography

Treatment of Cervical strain and sprains Medication: NSAID, muscle relaxants l Local injection with steroid(may be guided by sonography), prolothrerapy, shockwave therapy, PRP therapy l Physical modalities: PRICE, superficial/deep heat therapy, TENS therapy, cervical traction? l Programs of therapeutic exercise stretching and strengthening ex l

Shockwave therapy l During Shockwave therapy, a highintensity sound wave interacts with the tissues of the body l This leads to a cascade of beneficial effects such as neovascularisation ingrowth, reversal of chronic inflammation, stimulation of collagen and dissolution of calcium build-up l Stimulation of these biological mechanisms creates an optimal healing environment l As the injured area is returned to normal, functionality is restored and pain is relieved.

Platelet rich plasma injection therapy

Cervical radiculopathy and radicular pain

Definition of Cervical radiculopathy and radicular pain • A pathologic process involving neurophysiologic dysfunction of the nerve root • The seventh (C 7; 60%) and sixth (C 6; 25%) cervical nerve roots are the most commonly affected

Pathophysiology of Cervical radiculopathy and radicular pain Herniated intervertebral disk (HIVD) l Inflammatory response l Cervical spondylosis: ligamentous hypertrophy, hyperostosis, disk degeneration and zygapophyseal joint arthropathy l

Cervical intervertebral disc herniations

l l l Intervertebral discs are located between the vertebral bodies of C 2 -C 7 The discs are composed of an outer annular fibrosis and an inner nucleus pulposus and serve as force dissipators, transmitting compressive loads throughout a range of motion (ROM) The intervertebral discs are thicker anteriorly and therefore contribute to normal cervical lordosis

l The foramina are largest at C 2 -C 3 and progressively decrease in size to the C 6 -C 7 level l The nerve root occupies 25 -33% of the foraminal space l The neural foramen is bordered anteromedially by the Luschka (uncovertebral) joints , posterolaterally by facet joints, superiorly by the pedicle of the vertebra above, and inferiorly by the pedicle of the lower vertebra. Medially, the foramina are formed by the edge of the end plates and the intervertebral discs

Degeneration of the spines

Diagnosis of Cervical radiculopathy and radicular pain Thorough history and physical examination l Locations of pain regarding different level of C spines l Exacerbating factors l Imaging studies: X-ray, CT scan, MRI, bonescan (if necessary) l Electrodiagnostic evaluation l

Cervical radicular pain patterns

Referred pain patterns of cervical facet joints

Red flags !! l l l Weakness of limbs such as impaired fine motor or coordination abilities of hands or gait change Progressive neurological deficits Muscle atrophy Symptoms of neurogenic bladder such as incontinence Severe, unusual pain such as nocturnal pain, obvious knocking pain along spines Combined with other systemic condition such as fever

Cervical astrocytoma metastasis

C 1 -2 subluxation/ dislocation

Compression fracture

spondylolsithesis

Ankylosing spondylitis/Sp. A/rheumatoid spondylitis/spondyloarthropathy: bamboo spine

Infectious spondylodiscitis: radiographies

Treatment of Cervical radiculopathy and radicular pain Physical medicine and rehabilitation l Medications: oral NSAIDs, local injection with steroid l Stabilization and functional restoration l Invasive procedures l surgery l

Target zones for nerve block

IMMOBILIZATION l l For patients with acute neck pain secondary to radiculopathy, a short course (one week) of neck immobilization may reduce symptoms in the inflammatory phase Although the effectiveness of immobilization with a cervical collar has not been proven to alter the course or intensity of the disease process, it may be beneficial in some patients.

TRACTION l l l Continuous VS intermittent Home cervical traction units may decrease radicular symptoms. In theory, traction distracts the neural foramen and decompresses the affected nerve root, reduced the pressure in discs, helps open the facet joints and release the tight neck muscles Typically, eight to 12 lb of traction (1/8 to ¼ body weight) is applied at an angle of approximately 24 degrees of flexion for 15 - to 20 -minute intervals Traction is most beneficial when acute muscular pain has subsided and should not be used (or with extreme caution) in patients who have signs of myelopathy A recent systematic review of mechanical traction for neck pain of more than three months duration, with or without radicular symptoms, found insufficient evidence to recommend for or against its use in the management of chronic symptoms

PHYSICAL THERAPY AND MANIPULATION l l l restoring range of motion and overall conditioning of the neck musculature In the first six weeks after onset of pain, gentle range-of-motion and stretching exercises supplemented by massage and modalities such as heat, ice, and electrical stimulation may be used As the pain improves, a gradual, isometric strengthening program may be initiated with progression to active range-of-motion and resistive exercises as tolerated

Myofacial Pain Dysfunction Syndrome (MPDS)

Terminology: muscle pain versus myofascial pain Muscle pain: widespread, aching pain that appears to emanate from muscles together with tenderness over the muscles l Myofacial pain: a more complex term, a regional pain syndrome characterized by the presence of myofascial trigger points( Tr. Ps), taut band, slow twitch responses and referred pain l

l l l regionalized aching and poorly localized pain in the muscles and joints sensory disturbances, such as numbness in a characteristic of distribution the type of pain felt is characteristic of the muscle involved An acute onset may occur after a specific event or trauma (eg, moving quickly in an awkward position), while chronic pain may result from poor posture or overuse disturbed sleep. Persons with cervical and periscapular myofascial pain may have difficulty finding a comfortable sleeping position They may or may not be aware of muscle weakness in the affected muscles and may have a tendency to drop things.

Trigger points l l l focal point tenderness reproduction of pain upon trigger point palpation hardening of the muscle upon trigger point palpation (taut band) pseudo-weakness of the involved muscle, referred pain, and limited range of motion following approximately 5 seconds of sustained trigger point pressure under the load of 4 kg Slow twitch response

End plate

Management of MPDS l l l Physical modalities Massage therapy using trigger-point release techniques Physical therapy involving gentle stretching and exercise is useful for recovering full range of motion and motor coordination Aerobic exercise: start low and go slow Once the trigger points are gone, muscle strengthening exercise can begin, supporting long-term health of the local muscle system

Management of MPDS l l l Anti-depressants (primarily. SNRi. Is), anticonvulsants such as pregabalin (Lyrica), and msucle relaxants such as Baclofen Myofascial release, which involves gentle fascia manipulation and massage, may improve or remediate the condition Dry needling/acupuncture Trigger point injections using local anaesthetic such as Lidocaine or plus steroids; Botulinum toxin Posture evaluation and ergomatics Yoga, Taichi

Trigger point release by therapeutic ex l Trigger point therapy involves the use of various other techniques including active contract/relax and postisometric relaxtion, vapocoolant spray and stretch and ultrasound.

Dry needling injection l l l Trigger points are created at the muscular endplate This endplate becomes dysfunctional, creating a localized contracted state (with more Ach) The needle disrupts the dysfunctional endplates forcing the body to repair them The needling process also stimulates certain nerves to block pain sensations Compared to acupuncture

Thank you for your attention. Any questions or thoughts?