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Treatment of Neck and Back Pain

Treatment of Neck and Back Pain

Vinayagam Deiva Sigamani

BSc BPT APTA (USA), MIAP, MA (PSY), MPT (Sports Medicine) PGD Sports Med and ALT Med, DPM and DRM (New York)

Principal, Professor and Head of Department AMS College of Physiotherapy Anna Salai, Chennai

Head of Department AMS College of Physiotherapy Anna Salai, Chennai JAYPEE BROTHERS MEDICAL PUBLISHERS (P) LTD

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Treatment of Neck and Back Pain

© 2007, Vinayagam Deiva Sigamani

All rights reserved. No part of this publication should be reproduced, stored in a retrieval system, or transmitted in any form or by any means: electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of the author and the publisher.

This book has been published in good faith that the material provided by author is original. Every effort is made to ensure accuracy of material, but the publisher, printer and author will not be held responsible for any inadvertent error(s). In case of any dispute, all legal matters are to be settled under Delhi jurisdiction only.

First Edition: 2007

ISBN 81-8061-881-1

Typeset at JPBMP typesetting unit

Printed at

Gopsons Papers Ltd, A-14, Sector 60, Noida 201 301, India

To My Father Sri K Vinayagam

Preface

This book has been written to provide knowledge in treatment techniques to implement therapy and care of a person who is suffering from upper back and lower back pain with various pathological medical conditions.

In a modern world, everybody would prefer to take treatment without any adverse side-effects, naturally people shall prefer Physical Therapy to relieve pain and modify muscle tone, prevent disability and promote balanced body mechanism. This book helps, how to implement therapeutic way of healing the back pain by correct selection of physical therapy approaches and do’s and don’ts for the day-to-day daily activities. However, any treatment whether in clinical approaches, dogmatic approach and psychological approaches, their concept is to neutralize the body’s energy flow by either activates energy field or feeds from external or internal through different means to achieve the well-being state of normal healthy human system. The topics, which I have written in multidimensional ways based on my experience.

I hope this topic will enrich the knowledge of the students, young medical graduates and back pain sufferers to learn complete understanding of Cervical, Thoracic and Lumbosacral pain.

I have tried my level best to avoid errors and discrepancies, if

reader note any, might be brought into my knowledge for re-correction, will be appreciated. Reader must cross check from the text and clinically experienced expertise prior to send the suggestions for further clarification. Of course, any medical practice is an Art and Science effects may varies, depends upon the reliability and validity. This work was like my first mission, in fact, sharing my knowledge with readers. Hope this book will help the health care providers and back pain sufferers. I am sure, they will certainly be in a position to render very rewarding services to the patients.

viii Treatment of Neck and Back Pain

Finally, through this book, I have given how to manage patient suffering with back pain. Although we are dressing the wound, certainly God only heals it”.

Vinayagam Deiva Sigamani

Acknowledgements

This book would not have been possible without the help and encouragement of Janab Segu S. Jamaludeen, Secretary and Corres- pondent of AMS group of Educational Institutions. He has provided best environment and support for writing this textbook “Treatment of Neck and Back Pain”.

I would like to express my thanks to all my teachers who gave me

valuable suggestions to finish this project. Dr Francis Lillypushpam, Senior Physiotherapist has made helpful comments on sections of the manuscript, which has helped to shape up this text.

In fact, I have learned from my students, patients and teaching staff in clinics for many stimulating discussions in Back Pain over a year. However, thorough practical knowledge of back pain could be used to understand and treat patient’s problems.

I express my thanks to Mr M Govindan, Dr M Ramesh Babu

(PT), Dr J Julie Sangeetha (PT), Dr Sangeetha Mohan (PT) and Dr KG Smitha (PT) and our teaching staff who helped and made this possible.

Contents

1. Introduction

1

2. Anatomy and Biomechanics

3

3. Pain

18

4. Posture

26

5. Brachial Neuralgia

36

i. Cervical Spondylosis

38

ii. Cervical Disc Prolapse

39

iii. Brachial Plexus Lesion

40

iv. Thoracic Outlet Syndrome

43

 

a. Cervical Rib

45

b. Pectoralis Minor Syndrome

46

c. Claviculo Costal Syndrome

46

d. Anterior Scalenus Syndrome

46

e. Neurological Amyotrophy

47

v. Brachial Neuralgia Assessment

48

vi. Treatment of Cervical Conditions

55

6. Low Back Pain

77

i.

Intervertebral Disc Prolapse

78

ii.

Sciatic Nerve

85

iii.

Lumbar Spondylolisthesis

90

iv.

Lumbar Spondylosis

94

v.

Lumbar Stenosis

95

vi.

Osteoporosis

96

vii.

Idiopathic – Spina Bifida

96

viii.

Spinal Osteitis

98

ix.

Assessment for Low Back Pain

98

x.

Fitness Test

100

xii Treatment of Neck and Back Pain

xi. Physical Therapy for Low Back Pain

105

xii. Low Back Pain Surgical Procedure and Treatment

120

xiii. Ergonomics

123

xiv. Low Back Pain and Sex

136

Bibliography

139

Index

141

C HAPTER

1

Introduction

Man identifies from animal by his erect posture. Erect spine and posture considered as social highness, improves his personality and braveness. Backbones aids for erect posture, vertebral bones connected by ligaments and disc covered and coated by muscles. (Fig. 1.1) Pain in the back is a complex multifaceted health problem that represents excitatory challenges to health care provider. Back pain affects the physical, psychological, emotional, financial and social aspects of a person’s life. Physiotherapists are health care provider well trained in the psychosocial and physical aspects of rehabilitation, in fact, an important medical professional member of the health care team.

rehabilitation, in fact, an important medical professional member of the health care team. Fig. 1.1: Vertebral

Fig. 1.1: Vertebral column

2 Treatment of Neck and Back Pain

2 Treatment of Neck and Back Pain Fig. 1.2: Vertebral load The treatment and prevention of

Fig. 1.2: Vertebral load

The treatment and prevention of back pain have increased the attention in the community because of high cost of health care. Also diminishes ability to perform the day-to-day activities. Person who sit prolonged period causes more stress on their back. Almost 90 percent of backaches are due to spasm of back muscles. Such aches are sooner or later go away. However, backache is present because of muscle spasm than think about any pathology that you may live with it. However, you can reduce the discomfort by reconditioning your back by therapeutic exercise and analgesics, physical agents with correct ergonomics of course every treatment counts with positive mental attitude. The succeeding chapter would give all the aspect of back pain and treatment. (Fig. 1.2)

CHAPTER

2

Anatomy and Biomechanics

Axial skeleton forms upright of the body. It consists of head, thorax, trunk and it has total number of 80 bones. Appendicular skeleton attaches number of axial skeleton which contain 126 bones. We have totally 206 bones in our body. Bone is made up of 1/3rd organic (living) material and 2/3rd inorganic (nonliving) material. Organic material gives elasticity, inorganic provides hardness, strength which makes the bone opaque on the X-ray reading.

Vertebral Bones and its Spinal Segments (Fig. 2.1)

Vertebrae

Vertebral segments

Spinal segments

Cervical

7

8

Thoracic

12

12

Lumbar

5

55

Sacral

5

5

Coccygeal

1

1

8 Thoracic 12 12 Lumbar 5 55 Sacral 5 5 Coccygeal 1 1 Fig. 2.1: Vertebral

Fig. 2.1: Vertebral curves

4 Treatment of Neck and Back Pain

BACK BONES (Fig. 2.2)

Structure

Cervical

Thoracic

Lumbar

• Size

• Smallest

• Intermediate

• Largest • Large oval

• Body

• Small oval

• Heart shaped facets to connect ribs

• Vertebral foramen• Large triangular

• Smallest

• Intermediate • No foramen

• • Foramen for verte- • Facets connects ribs

Transverse

process

bral artery, short,

long, thick point post- • No

point laterally

eriorly and laterally

articulations

• Spinous

• Short, shout bifid

• Long slender point

• Thick point

process

inferiorly

posteriorly

• Superior articular • Face posterior

• Face posteriorly

• Face medially

process

and laterally

• Vertebral

• Equal depth

• Deeper inferior

• Deeper inferior

notches

notch

notch

• Deeper inferior notches notch notch Fig. 2.2: Vertebral parts (Typical Lumbar Vertebra) VB

Fig. 2.2: Vertebral parts (Typical Lumbar Vertebra) VB indicates vertebral body: P. Pedicle; TP, Transverse process; SP, spinous process; L. Lamina; SAP, superior articular process; IAP, inferior articular process; Saf, superior articular facet; iaf, inferior articular facet; MP, mammillary process; AP, accessory process; Vf, Vertebral foramen; RA, ring apophysis; NA, neural arch.

Anatomy and Biomechanics 5

PARTS OF VERTEBRA (Fig. 2.3)

1. Spine and spinal column and vertebral column are synonymous terms referring to the bony components housing the spinal canal.

2. Facet is a small, smooth flat surface on a bone found on thoracic vertebrae at the point of contact with a rib. Facet joints is the articulation between the superior articular process of the vertebrae below the inferior articular process of vertebrae above.

3. Body primarily cylindrical mass of cancellous bone, anterior portion of the vertebra at the major weight bearing structure. It is not present in atlas (C1) and axis (C 2 ). Between C 3 and S 1 bodies progressively larger.

4. Neural arch also called vertebral arch, posterior portion of vertebra with many different parts.

5. Vertebral foramen opening formed by joining of the body and neural arch through which the spinal cord passes.

6. Pedicle portion of neural arch just posterior to the body and posterior to the lamina.

7. Lamina posterior portion of the neural arch that unites from each side in the midline.

8. Transverse process formed the union of the lamina and pedicle.

9. Vertebral notches depression located on the superior and inferior surfaces of the pedicles.

10. Intervertebral foramen opening formed by superior vertebral notch of vertebra below the inferior vertebral notch of the vertebra above.

vertebral notch of vertebra below the inferior vertebral notch of the vertebra above. Fig. 2.3: Superior

Fig. 2.3: Superior view vertebra

6 Treatment of Neck and Back Pain

11. Articular process projecting superiorly and inferiorly off the posterior surface of the each lamina, superior articular processes face posteriorly on medially, inferior processes face anteriorly or laterally (Fig. 2.4).

12. Spinous process posterior projection on the neural arch, located at the junction of the two lamina.

13. Intervertebral disk articulates with adjacent bodies. They are 23 in number. They absorb and transmit shock and maintain flexibility of the vertebral column. Disk makes 25 percent of length of the vertebral column.

Pelvic Girdle

Following bones forms the pelvic girdle.

1. Sacrum

2. Coccyx

3. Hip bones comprised ilium, ischium, pubis

Joints of Pelvis

• Posterior laterally –

Sacroiliac joints

• Anteriorly

Pubis symphysis

• Superiorly

Lumbosacral

Sacroiliac Joints

• Synovial and Non-axial joint.

• The normal lumbosacral angle is 30 degrees.

Joints • Synovial and Non-axial joint. • The normal lumbosacral angle is 30 degrees. Fig. 2.4:

Fig. 2.4: Side view of vertebra

Anatomy and Biomechanics 7

PELVIC TILT

Anterior Pelvic Tilt

Anterior superior iliac spine of the pelvis move anteriorly and inferiorly closer to the anterior aspect of the femur. Range of motion: Hip flexion, lumbosacral extension Muscles: Hip flexors, spinal extensors

Posterior Pelvic Tilt

Posterior superior iliac spine moves posteriorly and inferiorly close to the posterior aspect of femur. Range of motion: Hip extension, lumbar flexion Muscles: Hip extensors, spinal flexors Standing stability is done by hip flexors and spinal extensors.

Lateral Pelvic Tilt

• Hip hiking side hip adduction.

• Hip drop side hip abduction.

• Lumbar curve convexity on hip drop side.

Muscles: Elevated side quadratus lumborum Drop side reverse pull of gluteus medius. Passive support done by iliofemoral ligament and iliotibial band on elevated side (standing leg).

Pelvic Rotation

When unsupported side of the pelvis move forward it is called forward rotation of the pelvis. The trunk concurrently rotates opposite and the femur on stabilized side concurrently rotates internally. When unsupported side of the pelvis moves backward, it is known as backward rotation of pelvis. Trunk rotates forward, femur on the stabilized side rotates externally.

Lumbar Pelvic Rhythm

Open chain movement of hip, pelvis and lumbar spine reaching the floor by flexion of trunk and extended knee. Hip can flex 90 degrees with anterior pelvic tilt than lumbar spine incline the trunk forward by 45 degrees. (Fig. 2.5)

8 Treatment of Neck and Back Pain

8 Treatment of Neck and Back Pain Fig. 2.5: Lumbar pelvic rhythm PRIME MOVERS OF NECK

Fig. 2.5: Lumbar pelvic rhythm

PRIME MOVERS OF NECK

Action

Muscle

Flexion

Sternocleidomastoid

Extension

Splenius capitis

Splenius cervicis

Erector spinae

Lateral bending

Sternocleidomastoid

Splenius capitis

Splenius cervicis

Sclenes

Erector spinae

Rotation (same side)

Splenius capitis

Splenius cervicis

Rotation (opposite side)

Sternocleidomastoid

PRIME MOVERS OF TRUNK

Action

Muscle

Flexion

Rectus abdominus

External oblique

Internal oblique

Extension

Erector spinae

Transversespinalis

Interspinalis

Lateral bending

Quadratus lumborum

Erector spinae

Internal oblique

External oblique

Intertransversarii

Anatomy and Biomechanics 9

Contd

Action

Muscle

Rotation (same side)

Internal oblique

Rotation (opposite side)

External oblique

Transverse spinalis

Compression of abdomen

Rectus abdominus

External oblique

Internal oblique

Transverse abdominus

MUSCLE ACTION OF NECK

Action

-

Flex the neck

Muscles

-

Sternocleidomastoid

Nerve

-

Accessary nerve (cranial nerve XI)

Action

-

Second and Third cervical nerve Bilaterally neck flexion

Muscles

-

Unilaterally neck lateral bending Scalene

Nerve

-

Lower cervical nerve

Action

-

Bilateral extend head

Muscles

-

Unilateral rotate and laterally bend the head to same side Splenius capitis

Nerve

-

Middle and lower cervical nerve

Action

-

Bilaterally extend head at neck unilateral rotate

Muscles

-

and laterally bend the neck to same side Splenius capitis

Nerve

-

Middle and lower cervical

TRUNK ACTION

Action

-

Trunk flexion and compression of abdomen

Muscles

-

Rectus abdominus

Nerve

-

Seventh through twelfth intercostal nerves

Action

-

Bilaterally trunk flexion

Muscles

-

Compression of abdomen Unilaterally lateral bending rotation to opposite side External oblique

10 Treatment of Neck and Back Pain

Nerve

-

Eight through twelfth intercostals

Action

-

Nerve iliohypogastric nerve and ilioinguinal nerve Bilateral trunk flexion and compression of

Muscles

-

abdomen. Unilateral lateral bending and rota-tion same side Internal oblique

Nerve

-

Eight through twelfth intercostals, iliohypo-

Action

-

gastric and ilioinguinal nerves Compression of abdomen

Muscles

-

Transverse abdominus

Nerve

-

Seventh through twelfth intercostal, iliohypo-

Action

-

gastric and ilioinguinal nerves Bilateral extension of trunk

Muscles

-

Unilateral lateral bend Erector spinae

Nerve

-

Spinal nerve

Action

-

Bilateral extension of the trunk

Muscles

-

Unilateral rotation to the opposite side Transversospinalis muscles

Nerve

-

Spinal nerves

Action

-

Trunk rotation

Muscles

-

Interspinalis muscle

Nerve

-

Spinal nerve

Action

-

Trunk lateral bending

Muscles

-

Intertransversarii muscles

Nerve

-

Spinal nerves

Action

-

Trunk lateral bending

Muscles

-

Quadratus lumborum

Nerve

-

Twelfth thoracic and first lumbar nerves

ARTICULATIONS OF VERTEBRAL SEGMENTS

Cartilaginous Joint

Between vertebral bodies and disk.

Diarthrodial or Synovial Joint

Between superior articular process of one vertebrae and inferior articular process of adjacent vertebrae (these joints are called Zygapophyseal joints).

Anatomy and Biomechanics 11

Synovial Joint

Joint where the vertebral column articulates with the ribs and the skull.

MUSCLES OF SPINE

Muscles provide stability, mobility, strength and endurance. Paravertebral musculature of lumbar spine is divided in three groups:

• Psoas major and psoas minor

• Quadratus lumborum and intertransverse laterallis

• Lumbar back muscles

Psoas Major

It is a muscle for flexion of hip and can not flex lumbar spine. During sit-ups psoas major exerts compression of intervertebral discs.

Quadratus Lumborum

Principal action is flexion of the 12th rib during respiration. Weak action is to flex the lumbar spine laterally.

Intertransversarii Lateralis

Acts synergically with quadratus lumborum in lateral flexion of lumbar spine.

LUMBAR BACK MUSCLES (Fig. 2.6)

Muscle

Action

• Intertranversarii medialis

Serves in larger propriceptive transducers

• Interspinalis

Proprioceptive function

• Multifidus

Extend the lumbar spine

Control flexion

Oppose flexion during rotation of lumbar spine

• Longissimus thoracis

Unilaterally lateral flexion

Bilaterally saggital rotation and posterior translation of the lumbar vertebrae

• Iliocostalis lumborum

Similar like longissimus thoracis.

About 50 percent of extension power of the lumbar spine is provided by thoracic fibers of longissimus and iliocostalis muscles acting

12 Treatment of Neck and Back Pain

12 Treatment of Neck and Back Pain Fig. 2.6: Back muscles through the erector spinae aponeurosis.

Fig. 2.6: Back muscles

through the erector spinae aponeurosis. 50 percent is exerted by multifidus and 50 percent by intrinsic lumbar fibers of longissimus and iliocostalis.

LIFTING MUSCLE ACTION

Flexion in the forward position during lifting increase intradiskal pressure in lower area. Intra-abdominal pressure (IAP) first proposed by Bartelink in 1957. Contraction of abdominal muscles is closed glottis raise the intra- abdominal pressure, supporting the thorax and assist the back muscles to raising the weight. IAP increase systolic aortic blood pressure. According to Gracovetsky back extensors assist lifting by generate passive tension in the posterior ligamentous system and passive and active tension in the thoracolumbar fascia, IAP is low tension in thoracic lumbar fascia is reduced consequently extension movement decreased.

ROTATORS AND LATERAL FLEXORS

Rotation of trunk to left side need simultaneous contraction of right external oblique and left internal oblique. Right side requires left external oblique and right internal oblique.

Anatomy and Biomechanics 13

Lateral flexion same side iliocostalis, longissimus, spinalis, quadratum lumborum and serratus posterior superior. Unilateral contraction of quadratus lumborum will hike the hip or laterally tilt the pelvis in frontal plane. Psoas major acts to flex the hip when femur, pelvis and lumbar are fixed.

LIGAMENTS AND ITS FUNCTION

Vertebrae are supported by means of ligaments for maintaining stability and to prevent excessive motion. The ligament that supports the vertebral complex and functions are as follows:

Ligaments

Functions

• Anterior longitudinal ligament

Limit extension Limit flexion Limit flexion especially lumbar Limit flexion

• Posterior longitudinal ligament

• Ligamentum flavum

• Supraspinous

• Anterior atlanto-axial (continuation of anterior longitudinal ligament)

Limit extension

• Posterior atlanto-axial (continuation of ligamentum flavum

Limits flexion

• Tactorial membrane (continuation of posterior longitudinal ligament)

Limit flexion Limit flexion Limits lateral flexion Limits rotation –

• Interspinous

• Intertransverse

• Alar ligament

• Capsular ligament

INTERVERTEBRAL DISCS

Intervertebral disc constitutes 20–30 percent of the total vertebral height. It acts as:

• Shock absorber for spine

• Distribution of forces

• Pivot for movements

• Stability and integrity of spine Thickness of intervertebral discs is 3 mm in cervical. Greater the disc thickness will have the greater mobility.

14 Treatment of Neck and Back Pain

Intervertebral disc consists of three components:

a. Central gelatinous NUCLEUS PULPOSUS

b. Surrounding ANNULUS FIBROSIS

c. Pairs of vertebral endplates that sandwich the nucleus In newborn baby, there is a capacity of 88 percent fluid content, but in the age of 77, fluid content goes to 65 percent. Young disc will hold more fluid. Fluid and proteoglycans concentrations are highest in nucleus and lowest in annulus. Composition of nucleus pulposus and annulus fibrosis compounds of water, collagen and proteoglycans. Collagen consists of type I and type II. Type I fiber resist tensile force present in skin, tendon and bone, whereas type II resist compressive forces. Annulus fibrosis consists of concentric laminae of collagen fibers, arranged in rings and keep the nucleus under constant pressure. Vertebral endplates are cartilaginous structures that cover the superior and inferior surfaces of each vertebral body within the area encircled the ring apophysis. The two endplates of each disc cover nucleus pulposus in and annulus fibrosus out. Innervation for intervertebral disc are vertebral and sinuvertebral nerves. Nutrition are through diffusion via cartilaginous end plate.

Glycosaminoglycane

Chemically they are long chains of polysaccharides. Each chain consists of repeated sequence of two molecules called “Repeated Unit”. Repeating unit consists of sugar molecules with an amine attached. The length of the individual GAG’s characteristically about 20 repeating unit. Repeating unit in human intervertebral disc are:

• Chondroitin 4 sulphate (fluid attraction capacity maintained)

• Chondroitin 6 sulphate

• Keraton sulphate

• Hyaluronic acid

Proteoglycans

These molecules consisting of glycosaminoglycans are linked to proteins, 2 basic forms:

1. Proteoglycon units

Anatomy and Biomechanics 15

Proteoglycon units are formed when several glycoaminoglycons

are linked to a polypeptite chain known as “Core Protein”. Proteoglycon aggregates are formed when several proteoglycon units are linked in

a chain of hyaluronic acid. A single hyaluronic chain may bind 20 to

100 proteoglycon units. The linkage between proteoglycon units and hyaluronic acid is stabilized by a small mass of protein known as “Link Protein”.

Collagens

It consists of strands of protein molecules. The fundamental units of

collagen is Tropocollagen molecule, consists of three polypeptide chains rounded around one another in helical fashion and held together end to end by hydrogen bonds. There are two types of collagen found in connective tissue. The principle type of collagen found in the intervertebral disc is type I and type II.

LOADED STATE OF DISC AND SELF STABILIZATION OF INTERVERTEBRAL JOINTS

When vertebrae compression force works on intervertebral disc nucleus bear 75 percent force and the annulus fibrosis 25 percent. However, in the horizontal plane, nucleus transmits some of the forces in to annulus. If a disc is exposed a violent force, the thickness of the disc exhibits dampened oscillation over a period of one second. If this force is too violent the intensity of this oscillatory reaction can destroy the fibers of the annulus, this is the cause of deterioration of the intervertebral disc exposed to repeated violent stresses.

WATER INHIBITION OF NUCLEUS

When the nucleus rest in the intervertebral disc, there is numerous microscopic pore linking the nucleus and the vertebra. During standing, water contained with the gelatinous matrix of nucleus escapes in to the vertebral body through these pores. These static pressure is maintained throughout the day, during night nucleus contain more water than in morning. So the disc is thicker. This is 2 cm in healthy person. During night, when one lies flat, the vertebral bodies not in force of gravity or muscle. At this time, the water absorbing capacity of nucleus great, so it takes back the water from the vertebral bodies, disc regain its original thickness. (Fig. 2.7)

16 Treatment of Neck and Back Pain

16 Treatment of Neck and Back Pain Fig. 2.7: Loading over vertebral column This is reason

Fig. 2.7: Loading over vertebral column

This is reason one is taller in the morning than at night, and also flexibility is marked at time. With aging water absorbing capacity is decreased. Each vertebra can be compared to a system of first order. Zygapophyseal joints are fulcrum, interverterbal disc weights and paravertebral muscles are effort. Disc thickness is at lumbar is 9 mm, thoracic is 5 mm, and cervical is 3 mm. Disc/body ratio is at lumbar is 1/3, thoracic is 1/5, and cervical is 2/5. Greater the ratio, greater mobility. (Fig. 2.8)

SPINAL CORD

Spinal cord is the lower elongated cylindrical part of the Central Nervous System (CNS). It extends from upper border of the Atlas to the lower

the Central Nervous System (CNS). It extends from upper border of the Atlas to the lower

Fig. 2.8: Inter vertebral disc

Anatomy and Biomechanics 17

border of the Vertebra L 1 or upper border of L 2 Vertebra. It is about 45 cm long. The lower end of conical end called “Conus Medullaris”. Continuation of the medulla, spinal cord runs within the vertebral canal from foramen magnum to the cone-shaped conus medullaris at the level of the second lumbar vertebra. Below the L 2 collection of nerve roots running down from the spinal cord like horse tail, hence it is named as “Cauda Equina”. Cauda equine made up of the nerve roots from L 2 through S 5 . A thread like non-neural filament running from the conus medullaris called “Filum Terminale. Spinal cord is approximately 17 inches in length protected by three layers as brain. Cerebrospinal fluid flow in between arachnoid layer and pia matter. Vertebral foramen is the passage for the spinal cord, protected by bony structure of each individual vertebra, intervertebral foramen located on the sides of the vertebral column. Intervertebral foramen is formed by superior vertebral notch of the vertebra below at the inferior vertebral notch of vertebra above. Through this opening spinal nerve root exists the vertebral canal. Cross sectional view of the spinal cord shows center gray matter and peripheral white matter. Grey matter is middle of the cord in “H” shaped or butterfly shape. Top portion of the “H” is posterior horn responsible for transmitting sensory inputs lower portion of the anterior horn, transmits motor impulse.

CHAPTER

3

Pain

Pain is defined as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage. Result of muscle spasm and guarding or protection of injured part (protective spasm). Prolonged spasm which leads to circulatory deficiency, muscle atrophy, disuse habits, conscious or unconscious guarding.

PURPOSE OF PAIN

Pain is a protective mechanism for the body, occurring whenever any tissues are being damaged and it causes the individual to react to remove the pain stimulus. Acute pain is useful pain, a symptom of disease in trauma, lasting for 3 months. Head and lower limbs are the most common sites of acute pain. Chronic pain has lost its biological purpose, e.g. arthritis, cancer, lasting for at least 6 months. Back is the most common site for chronic pain. Pain without an organic pathology called chronic pain syndrome. Behaviour of pain is characterized by verbal expression, grimacing, guarding movement, decreased activity levels, limited range of movement of joint and also overuse of pain relieving medications, signs of depression and viability to work.

AETIOLOGY OF PAIN

• Somatic

• Neuropathic

• Psychogenic

• Viral, Bacterial, Fungal

• Inflammatory

• Degenerative

• Neoplastic

Pain 19

• Ischemic

• Endocrine, metabolic

• Autoimmune

• Traumatic

FACTORS AFFECTING PERCEPTION OF PAIN

Personality

Extroverts express pain freely. Introverts feels the pain intensely but complain less.

Social Context

Pain is perceived during wars, electric surgery, labour, ceremonies.

Culture

Face or withdraw pain alone openly seek help or support. Pain is necessary evil for further spiritual benefits.

Past Experience of Pain

Child birth.

State of Mind

Anxiety, depression, increases the perception of pain.

PAIN RECEPTORS

Receptors in the skin called nociceptors (noceicep-damage) or free nerve endings. Nociceptor neuron present in dorsal root ganglion, near the spinal cord, which transmit pain signal afferent neuron or nerve fibers conduct impulses from periphery to brain. Efferent neuron conduct impulses from brain to periphery. Once nociceptor is stimulated, it releases neuropeptide (substance “P”) goes towards the afferent neuron to spinal tract. Free nerve endings present in periosteum, arterial wall, joint surfaces, falax and tentorium of cranial vault.

TYPES OF PAIN

Fast Pain (Pin Prick)

Transmitted “A” delta fibers, processed in spinal cord. Dorsal horn

20 Treatment of Neck and Back Pain

lamina—later spinothalamic tract. Transmits pain at a speed of 15 m/ second.

Slow Pain (Aching, Throbing, Burning)

Transmitted through “C” fibers. It is totally protective, aversive reaction. Response medial spinothalamic tract transmit at a speed of 1 m/second. When a person experiencing pain following signs can be take place:

• Increase heart rate

• Increase blood pressure

• Pupillary dilatation

Sweating

Hyperventilation

Anxiety

Protective behaviour

STIMULATION OF PAIN

Mechanical

Pain last only as long as the deformation is present and resolves when deformation is corrected.

Thermal

Pain occurs when noxious chemical substances occur in quantities is sufficient to irritate the nociceptors.

Chemical

Pain is dull relieved when concentration of chemical returns to subthrushold level. Emotional psychological aspect of pain are projection to limbic system. Pain memory storage areas present in temporal lobes.

ORIGIN OF PAIN

Pain from the Central Nervous System

Central nervous system pain can occur immediately after the insult pain from injury to the dorsal horns felt ipsilateral side. Pain from cortical lesion felt face, hand and feet.

Pain 21

Pain from Autonomous Nervous System

Sympathetic and parasympathetic fibers travel in the wells of blood vessels. Automatic pain is spread throughout the involved vessels distribution.

Pain from Thalamic (Thalamic Pain)

Usually in contralateral extremities, elicited by movement, skin contact, heat, cold and vibration.

Pain from Periphery

Pain results from noxious irritation of the nociceptors. Nature of the pain may be parasthesia, pins and needles, e.g. diabetic neuropathy.

Referred Pain

Pain is not felt at the site of the pathology, but distant location, e.g. pain in the jaw, neck, radiate upper limb due to angina.

COGNETIVE BEHAVIORAL METHOD TO PAIN RELIEF

1. Relaxation exercises—deep breathing, Jacobsons training (reversing endorphin depletion).

2. Aromatherapy

3. Hydrotherapy - General

4. Hypnosis

5. Operant conditioning

6. Music

7. Group therapy

8. Biofeedback

9. Body scanning Reiki and Pranic Healing.

Other Methods

i. Behaviour modifications –

1. Learn the difference

2. Between hurt and harm

3. Grade exercise

22 Treatment of Neck and Back Pain

ii. Yoga

iii. Guided imagery

iv. Positive reinforcement and educational support

v. Teaching coping skills –

1. Relax, pacing activity

2. Distraction technique

3. Cognitive restructuring

4. Problem solving

PHYSIOTHERAPY TREATMENT IN PAIN

1. Tens

2. Heat and cold therapy

3. Electrical nerve stimulation

4. Manipulative procedure— Massage and mobilization

5. Traction

6. Hydrotherapy

7. Counter irritant

8. Therapeutic exercises—daily walking, posture, strengthening of

muscles, range of motion exercises. Analgesic physical agents used in physiotherapy to slow or block the impulses ascending along the “C” afferent neural pathways. Enkephalines and seratonin active in descending pathways thought to block the pain message.

Physical Agent (Analgesic Type) Effects as follows:

1. Moderating the release of inflammatory medications.

2. Modulating pain at the spinal cord level.

3. Altering nerve conduction

4. Increase endorphin level.

INHIBITARY MECHANISMS

1. Blocking the pain: Impulse through afferent pathway called “Gate control theory” and

Pain 23

Gate Control Theory

For example, Rubbing massage. Ascending impulses on these A delta and C fibers stimulate substantia gelatinosa when the stimulus enter the dorsal horn of spinal cord. Stimulated substantia gelatinosa inhibits synaptic transmission in the large and smaller afferent fibers. Depends upon the input from the small and large diameter afferent determines the pain message is blocked or gated.

Descending Pain Control

Pharmacological Approach of Pain Management

Systemic Analgesics

1. Non-steroidal anti-inflammatory drugs (NSAIDs)

2. Acetaminophen

3. Opiates and opioids

4. Antidepressants.

1. NSAID’s

Side Effects

1. Gastro intestinal bleeding or irritation

2. Decreased platelet aggregation and thus prolonged bleeding time

3. Kidney damage

4. Bone marrow suppression

5. Rashes, anorexia

6. Decreased renal blood flow in dehydrated patients.

Drugs

Asprin

Ibuprofen

Naproxen sodium

Piroxicam

2.

Acetaminophen (Mild to Moderate Pain)

Side effect: Prolonged use can damage liver.

Drug: Tylenol

3. Opitates (Narcotic drug that contain opium) Used for post-operative pain.

24 Treatment of Neck and Back Pain

Side effects: Nausea, vomiting, sedation, suppression of cough.

Drug: Morphine, hydromorphine, fentanyl, meperidine.

4. Antidepressents (for chronic pain)

Drug: Amitryptiline (elavil)

Spinal Analgesia

Drug: Opitates, local anaesthesia, corticosteroids

Procedure

Inject in to the epidural or subarachnoid space of the spinal cord. Fat soluble opiates have rapid action. Water soluble opiates have slow action. It blocks the nociceptor in the spinal column.

Side Effects

Fat and muscle wasting, osteoporosis, cushings syndrome—symptoms.

Local Injection

Administered corticosteroid and local anaesthesia in the joints, bursa, trigger points around tendon.

Side Effects: Tissue breakdown, deterioration.

(Note: For acute trauma, this drug is not administered, because it reduces the inflammatory response and may impair healing of structures.)

PSYCHOLOGICAL ASPECT OF BACK PAIN

Physiologically pain is a warning sign of bodily dysfunction, but psychologically it can be a cry for sympathy or expression of guilt. At a deep level aggression may be sublimated turned for defense, used for punishment and enclosed in love and sympathy. Physical illness and disability may satisfy security and dependence needs without stigmatizing the patient, because the sick role is accepted by most societies. In addition, patient may wish to continue the financial support which the disability allows, with through Insurance, Government or Family.

Pain 25

Psychiatric evaluation may help to unravel symptoms and signs in such patients. Look at the chart how emotional factor causes back pain.

Look at the chart how emotional factor causes back pain. Three factors must be consider for

Three factors must be consider for back pain:

1. Emotional

2. Changes in muscles

3. Changes in facet

The most common emotional disturbance for low back pain are Tension, Stress, Anxiety, Fear, Resentment and Depression. Emotional disturbance acts through automatic nervous system to produce local areas of vasoconstriction of muscles. Changes in histological zones in muscle have been variation by several different investigations. Multifidus muscle is rotator of lumbar and also postural muscle which is controlled involuntarily. It is commonly affected. Controlled contraction produces rotational injury to facet joints and disc. Injury to this structure leads to reflex sustained contraction of muscle.

CHAPTER

4

Posture

Posture is defined as “a position or attitude of the body, the relative arrangement of body parts for a specific activity or characteristic manner of bearing one’s body”. Ligaments, faciae, bones and joints are inert structures that support the body, whereas muscles, tendinous attachments are the dynamic structures that maintain the body in a posture or move is from one posture to another. Gravity plays an important role to maintain upright posture of the body. Normally gravitational line goes through the physiologic curves of the spinal column and they are balanced. If the weight in one region shifts away from the line of gravity, the remainder of the column compensates the regain equilibrium. For weight bearing joint to be stable, or in equilibrium, the gravity line of the mass must fall exactly through the axis of rotation, or there must be a force to counteract the force of gravity. In body, the counter force is either muscle or inert structures. Upright posture, usually involves a slight anterior – posterior swaying of the body of about ‘4’

cm.

Pain Related to Poor Posture

Postural Fault

Posture that deviates from normal alignment but has no structural limitation pain due to mechanical stress for prolonged period pain relieved with activity. Muscles flexibility and strength are normal.

Postural Dysfunction

Adaptive shortening of muscles and weakness of muscles are involved

causes may be prolonged poor posture results contraction and tight-

ness.

Posture 27

Postural Habits

Flexibility and strength is essential following trauma or surgery. Good postural habits are important to avoid abnormal stresses on growing bones and adaptive changes in muscles and soft tissues.

Types of Posture

Static Posture

Body and segments are aligned and maintained in certain posture, e.g. lying or standing. Static posture control involves maintenance of particular posture against gravity.

Dynamic Posture

Body and body segments moving that is walking and running, jumping, throwing and lifting. Dynamic posture involves maintenance of stability during movements of the body. Human than the ability to arrange and to rearrange the body segments to form larger variety of postures such as bilateral single leg erect standing, sitting, lying down and kneeding, maintain erect bipedal stance is difficult. It allows person to use their upper extremities for the performance of large and small motor tasks. Erect posture increases work of heart increases stress on the vertebral column, pelvis and lower extremities and reduces stability. The human center of gravity located with the body at the level of second sacral segment is relatively distant from the basis of support. Maintain the static erect posture requires very little energy expenditure in the form of muscle contraction. The bones, joints, ligaments and able to provide the major torques needed counteract gravity, and frequent changes in body position assist in permitting circulatory return.

Postural Control

Person’s ability to maintain stability of the body segments in response to forces that threaten to disturb the body’s structural equilibrium. Central Nervous System able to respond to all of this input with appropriate output to maintain the equilibrium of the body. Musculoskeletal system must have a range of motion that is need for specific work. Muscle must respond with appropriate speeds and force.

28 Treatment of Neck and Back Pain

Central Nervous System receives and process information from all systems and must be interpret information from the receptors regarding the position of the body in space. When inputs altered or absent in weightless conditions during spacelight or decreased sensation in the lower extremities the control system must respond to incomplete or distorted data thus person posture may be altered.

NORMAL POSTURE

Standing

Lateral View (Plumb Line)

• Head

Through the ear lobe

• Shoulder

Through tip of the acromion process

• Thoracic

Anterior to the vertebral bodies

• Lumbar

Posterior to the vertebral bodies

• Pelvis

Level with an anterior or posterior tilt

• Hip

Through the greater tuberosity slightly posterior to the hip joint axis

• Knee

Slightly posterior to patella anterior to the knee joint knee extension

• Ankle

Slightly anterior to the lateral malleolus with ankle joint in neutral position.

Anterior View

• Head

Extended and level

• Shoulder

Level and not elevated or depressed

• Thoracic

Centered in midline

• Lumbar

Level with both ASIS in the same plane

• Pelvis

Slightly apart

• Hip

Level and not bowed or knock

• Knee

Normal arch in feet

• Ankle

Slight outward toeing

Posterior View

• Head

Extended not flexed or hyperextended

• Shoulder

Level

• Spinous process •

Centered in the midline

• Hip

Level with PSIS in same line

• Leg

Slight apart

• Knees

Level and not bowed or knock

• Ankle

Calcaneous should be straight

Posture 29

Sitting Position or Ischial Support (Typing)

Without resting on back of the chair, pelvis is in state of equilibrium. Trapezius in action to stabilize the vertebral column. In long sitting, this position becomes painful and the condition is called “Typist’s syndrome” or “Trapezius syndrome”.

Sitting on Ischio-Femoral Support

Flex the trunk in supported by ischeal tuberosities and posterior aspect of the thighs, trunk may be supported by arms resulting on knees. Flattening of lumbar curve. Trunk is stable with minimal muscular support and can fall asleep. Relax paravertebral muscles. Decrease the shearing forces on lumbosacral disc.

Sitting on Ischiosacral Support

Trunk rest on back of the chair, supported by ischial tuberosities, posterior sacrum, coccyx, pelvis tilted backward. Lumbar curvature flattend, thoracic curve increases, sleep is possible. Breathing hampered by neck flexion help reduces slipping of L 5 , relax posterior muscle and relieve pain of spondylolisthesis.

Supine with Extended Limbs

• Resting position

• Psoas is stretched

• Lumbar curvature exaggerated

Supine with Flexed Lower Extremities

• Relaxation of psoas

• Backward tilt of pelvis

• Flattening of the lumbar curvature

• Relax spinal and abdominal muscles

Supine with Semiflexed Lower Limbs with Elevation Head and Upper Trunk Mild Elevation

• Achieved with help of specially designed chairs

• Thoracic curvature accentuated

• Lumbar and cervical flattening

30 Treatment of Neck and Back Pain

Hip flexion

Psoas and hamstring are relaxed.

Side Lying

• Vertebral curved

• Thoracic convex superiorly

• Not relaxed

• Respiratory difficulty

Prone Lying

• Lumbar curvature exaggerated with respiratory difficulty

• Pushing back the viscera on to the diaphragm

• Pressure for over there hours sore will develop.

Disc Pressures in Various Positions

• Supine

25% of body weight

• Side lying

75%

• Standing

100%

• 20 Degree Mild Trunk Flexion

150%

• 40 Degree Moderate Trunk Flexion

220%

• Sitting (Typist)

140%

• Sitting Mild Tunk Flexion (Back unsupported)

185%

• Sitting with leaning Forward (Back unsupported)

275 %

• Slouched Posture with back support

Nearly 36 lbs

of weight compress the posterior structures. Least amount of intervertebral disc pressure occur while supine lying. Kneeding stool reduces disc pressure while sitting.

Common Faulty Postures

Lordotic Posture It is characterized by an increased lumbosacral angle (normal 30 degree). Increase in anterior pelvic tilt and hip flexion secondary to that increase thoracic kyphosis and forward head position. For example, pregnancy, obesity and weak abdominal muscles.

Posture 31

Relaxed or Slouched Posture (Sway Back)

It is characterized by excessive shifting of the pelvis segment anteriorly, resulting in hip extension and shifting of the thoracic segment posteriorly, resulting in flexion of the thorax on the upper lumbar spine. A compensation increased thoracic kyphosis and forward head placement are also seen. For example, attitude of a peuon, fatigue.

Flat low back

It is characterized by decreased lumbosacral angle, decreased lumbar lordosis and posterior tilt of the pelvis. For example, over emphasis of flexion exercise.

Flat upper back

It is characterized by decreased thoracic curve, depressed scapulae, depressed clavicle and an exaggeration of axial extension, flexion of the occiput on atlas and flattening of the cervical lordosis, e.g. exaggerated upright posture.

Cervical Region

Forward Head Posture It is characterized by increased flexion of the lower cervical and upper thoracic regions. Increased extension of the occiput on the first cervical vertebra, increased extension of the upper cervical vertebra. May be temporomandibular dysfunction with retrusion of the mandible, e.g. leaning forward for long period.

Flat Neck Posture Decreased cervical lordosis increased flexion of the occiput on atlas seen exaggerated military posture, temporomandibular problems and protraction of mandible.

Low Back Pain Due to Faulty Posture Abnormal pelvic tilt is a common feature which could occur as a result of various musculoskeletal imbalances. Habitual wrong posture result in muscular tightness eventually leading to fixed deformity. Trunk flexion or pelvic tilt wrong posture precipitate low back pain.

32 Treatment of Neck and Back Pain

Deformity

Causitive factor

• Pelvic tilt anterior

Weak abdominals

Tight low back muscles

Tight hip flexors

Tight tensor fascia latae

Weak hamstrings

• Posterior

Tightness and over development of low back muscles

• Lateral

Scoliosis (structural and functional)

Limb length discrepency

• Trunk flexion deformity

Cartilaginous locking in flexion to accom- modate protusion.

Posture is a position or attitude of the body relative arrangement of body parts for a specific activity. Gravity places stress on the structures responsible for maintaining the body in upright posture. Normally the gravity line goes through the physiologic curves of the spinal column and they are balanced.

Postural Problems and Pain

1. When muscle fatigue the load is shifted to the inert tissues supporting the spine at the end ranges with continuous load, creep and distention occurs in the inert tissues causing mechanical stress.

2. Continuous stress to pain sensitive structures such as joint capsule, blood vessels, ligaments, nerve endings which leads to pain. If the mechanical stress exceed then breakdown of tissues will occur.

3. If the muscle guarding is prolonged, result prolonged muscle contraction result buildup of metabolic waste products and reduced irritation. This altered local environment leads to irritation of free nerve endings. So the muscle forced to continue their contraction result becomes source of additional pain. Faulty posture strains ligaments will cause pain. If torn, there will be hyper mobility of the segment. Once healing complicated naturally adaptive shortening or scar formation leads to postural alignment. Repeated loading or twisting leads strain in lumbosacral fascia, quadratus lumborum, erector spinae, and iliolumbar ligament. Common site of injury is lumbar and iliac crest. Strain to upper thoracic muscle and fascia is common with postural stresses such

Posture 33

as prolonged sitting in faulty posture. Emotional stresses increases tension with the posterior cervical and lumbar region.

4. Postural fault is a posture that deviates from normal alignment. If a person maintain prolonged period of faulty posture strength and flexibility. Imbalance leads to postural pain syndrome. Good postural habits are necessary to avoid postural pain syndromes. In children, good postural habits are important to avoid abnormal stresses on growing bones and adaptive changes in muscle and soft tissues.

Lordotic Posture

Increase lumbar lordosis and increase anterior pelvic tilt and hip flexion. This posture seen person with thoracic kyphosis and forward head position.

Muscle Imbalance

Hip flexors, lumbar extensors.

Muscles Stretched

Stretching lead to weakness of abdominal muscles.

Source of Pain

Stress anterior longitudinal ligament, narrowing of posterior disc space and narrowing of intervertebral forament.

Common Causes

Pregnancy, obesity, sustained faulty posture, weak abdominal muscles and high heel shoes.

Relaxed Posture (Slouched)

This posture is also called sway back. Shifting of entire pelvic segment anteriorly result hip extension, thoracic segment moves posteriorly, result flexion of the thorax on the upper lumbar spine, this increases lordosis in the lower lumbar region, increase kyphosis in lower thoracic region.

Source of Pain

Stress to iliofemoral ligament, lower lumbar spine, posterior longitudinal ligament, stress to iliotibial band and narrowing of intervertebral foramen.

34 Treatment of Neck and Back Pain

Muscle Imbalance

Tight upper abdominal muscles, hip extensors, lower lumbar extensor.

Muscle Stretched

Lower abdominal muscles and hip flexor muscles.

Causes

Muscle are not properly used for support and attitudinal.

Flat Low Back Posture

Characterized by decreased lumbosacral angle, decreased lumbar lordosis, hip extension, posterior tilting of the pelvis.

Source of Pain

Umbar region, stress on posterior longitudinal ligament.

Muscle Imbalance

Trunk tight flexor and hip extensor

Stretches

Weak lumbar extensor and hip flexors

Causes

Flexing the trunk in sitting and standing and over dose of flexion exercise.

Round Back or Increased Kyphosis

Increase thoracic curve, protracted scapulae.

Source of Pain

Stress in posterior longitudinal ligament, fatigue of erector spinae, and thoracic outlet syndrome.

Muscle Imbalance

Tight intercostals muscles, muscles of upper extremities and originate from thorax.

Muscle Stretched

Weak thoracic erector spinae and scapula retractor.

Posture 35

Causes

Flat low back posture, continued slouching and over dose of flexion exercise.

Flat Upper Back

This posture decreases the thoracic curve, depressed scapulae, depressed clavicle flat neck posture (military posture).

Source of Pain

Fatigue of muscles and compression of neurovascular bundle.

Muscle Imbalance

Tight thoracic erector spinae, scapular retractors, weakness of scapular protraction and intercostals muscles.

Causes

Exaggerating the upright posture.

Scoliosis (Lateral Curvature)

Involves in thoracic and lumbar regions.

Source of Pain

Muscle fatigue and ligament strain on the side of the convexity, nerve root irritation on the side of the cocavity.

Muscle Imbalance

Tight structure on the concave side of the curve, stretched and weak structure on the convex side of the curve.

Causes

Hemivertebra, osteomalacia, rickets, asymmetry of hips, pelvis, lower limbs, muscle guarding, spasm and habitual.

CHAPTER

5

Brachial Neuralgia

Greek words Brachium

Arm

Nerve

Neuron Alcos

Pain radiating down the arm due to involvement of cervical spinal cord, vertebral and shoulder or pain in the nerves, supply the various parts of the arm.

Pain

Incidence: 25 to 40% > 45 years

Anatomy: 7

Cervical vertebra

Typical

3 to 6

Atypical

1, 2 and 7

Root Trunk Division Cord Branches

Brachial Plexus

Lateral Cord (LML)

1. Lateral pectoral nerve

2. Lateral root of median nerve

3. Musculocutaneous nerve

Medial Cord (4MU)

1. Medial root of median nerve

2. Medial pectoral nerve

3. Medial cutaneous nerve of arm

4. Medial cutaneous nerve of forearm

5. Ulnar nerve

Posterior Cord (SSLCR)

1. Upper subscapular nerve

Brachial Neuralgia 37

3. Nerve to latissimus dorsi

4. Circumflex nerve

5. Radial nerve

Nerve to serratus anterior, nerve to rhomboids (Dorsal scapular nerve)—arising from root. Suprascapular nerve, nerve to subclavions—arising from trunks. Rami, trunk lies above the clavicle. Division behind the clavicle between scalneus anterior and medius. Cord and branch lies infra- clavicular in the axilla.

CAUSES OF BRACHIAL NEURALGIA

A. Intra-spinal conditions (Irritation of intra-spinal origin of brachial plexus)

1. Spinal tumours

2. Syringomyelia

3. Chronic arachnoiditis

4. Meningo radiculitis

5. Extradural tumours

B. Brachial plexus injuries

C. Thoracic inlet syndrome (stretching the plexus)

1. Cervical rib

2. Scalenus anticus syndrome

3. Pectoralis minor syndrome

4. Descend of shoulder girdle—postural

5. Costo clavicular syndrome

D. Brachial neuritis

E. Functional causes

1. Hysteria

2. Psychoneurosis

3. Malingering

F. Thoracic outlet syndrome

BRACHIAL NEURALGIA—CLINICAL CHARACTER

• Disease of cervical spinal cord

• Cervical intervertebral disc prolapse

• Cervical spondylosis

• Tumor of cervical vertebra, root, meninges, spinal cord

• Tuberculosis of cervical spine

• Fracture dislocation of cervical vertebra

38 Treatment of Neck and Back Pain

• Infective brachial radiculitis

• Brachial plexus injuries

I. CERVICAL SPONDYLOSIS

Arthrosis or Degenerative changes in the intervertberal joints of the cervical vertebra including facet joints of spine.

Common Sites

C 4 C 5, C 5 C 6, C 6 C 7

Age

Above 30 years.

Pathology

1. Degeneration of disc begin in annulus fibrosis.

2. Collagen fibres becomes coarse.

3. Nucleus pulposus loses fluid becomes fibrous.

4. Nucleus gradually emerges with annulus.

5. Disc degeneration loses its height.

6. Osteophytes gives mechanical irritation.

Reduction of the heights leads narrowing of intervertebral foramen. Capsular thickening causes pressure on the nerve roots.

Clinical Features

1. Pain posterior aspect of neck.

2. Pain in the arm, no pain in neck.

3. Pain present in the dermatome of involved nerve roots of the upper limb.

4. Pain referred down to the thoracic area, medial border of scapula.

5. Muscle spasm of upper trapezius.

6. Coughing, sneezing, straining increases the discomfort in the arm.

Investigations

i. Radiology

1. Shows narrowing of joint space

2. Osteophytic changes

Brachial Neuralgia 39

ii. CT Scan

iii. MRI

II. CERVICAL DISC PROLAPSE

Lower cervical spine is a common site for acute brachial neuralgia.

Age

Between 20 – 55.

Sex

Male more prone than female.

Site

C 5 – C 6 and C 6 – C 7

Pathology

i. Disc protrusion: Secondary to trauma. Bulge of nuclear fluid through weak annulus. Sudden burst in the annulus causes nucleus to extrude.

ii. Disc extrusion: Split occurs in the annulus fibrosus and nucleus is under tension.

Clinical Features

1. Neck is stiff, neck muscles in spasm.

2. Pain in neck during active and passive movements.

3. Tenderness over C 5, C 6 and C 7 spinous process.

4. Range of motion limited.

5. Neck rigid, or slightly flexed towards the side of the lesion.

6. Abduction of shoulder, flexion and elbow relieve pain.

7. Pain worsens on coughing and sneezing.

8. Disc herniation causes sensory, motor, reflex changes.

Root

Motor

Sensation

Reflex

C 5

Levator scapulae,

Upper scapula, lateral aspect of arm

Biceps

rhomboids

C 4 – C 5

Suprasinatus infra-

spinatus deltoid

Contd

40 Treatment of Neck and Back Pain

Contd

Root

Motor

Sensation

Reflex

C 5

C

6

Biceps

]

 

Brachio–

C 6 C 7 C 8 C 7

 

Brachialis

radialis

]

Wrist flexion

Triceps

Outer border of forearm, thumb, index finger Index, Middle Finger

Investigations

1. Narrowing of affected disc space with sclerosis of adjacent vertebral border.

2. Anterior osteophytes formation forms after few attacks.

Diagnostic Methods

CT Scan

Thermography

Myelography

EMG Examination

MRI

Discography

III. BRACHIAL PLEXUS LESION

Disability in the upper limb, arm pain is lone factor that contributes in addition to the muscle paralysis and sensory loss.

Aetiology

1. Trauma and traction—Erb’s palsy, motor-cycle accidents.

2. Pressure during prolonged period—post-anaesthetic palsy.

3. Post-radiation fibrosis, electric shock.

4. Following surgery—removal of cervical rib.

5. Tumours.

6. Vascular lesion.

7. Inflammation.

Pathology

Two Types

1. Pre-ganglionic

2. Post-ganglionic

Brachial Neuralgia 41

Pre-ganglionic lesion

Here the nerve root are avulsed out of the spinal cord.

Post-ganglionic lesion

a. Injury to the nerve roots distal to the posterior nerve root ganglion. Two types of post-ganglionic lesion are:

1. Nerve roots, sheath are intact, axon disrupted

2. Nerve root intact rupture of nerve sheath.

b. Lesion involving upper trunk – Erb’s palsy (C 5 –C 6 )

c. Lesion involving lower trunk—Klumpke’s paralysis (C 8 –T 1 ).

Character of Pre- and Post-ganglionic lesion

Pre-ganglionic Lesions

Causes

1. Collision accident—high speed head.

2. Loss of consciousness associated injuries, e.g. fractures, head injuries.

Signs

1. Positive horner’s sign Sympathetic nerve supply to the eyes as it merges at T 1 root causes ptosis, miosis, anhydrosis, loss of ciliospinal reflex.

2. Positive sensory action potential.

3. Meningocoele in myelogram.

4. Crushing pain even at rest.

5. High cervical scoliosis.

6. Paralysis of Dorsal scapular muscle and serratus anterior results flail limbs.

Post-Ganglionic Lesions

History of slow speed trauma, person being thrown due to sudden half of vehicle. No injuries and loss of consciousness.

Signs

1. No Horner’s sign.

42 Treatment of Neck and Back Pain

3. Positive Tinel sign: Tapping along the course of nerve from distal to proximal. Tingling is felt in distribution of nerves. There are two sites of Tinel’s sign.

a. At the site of lesion.

b. At the point of regeneration.

Stronger distal sign indicates axonal regrowth at clinical recovery.

4. Complete lesion, all muscles of upper limb, excluding dorsal scapular muscles and serratus anterior and paralysed.

Root Avulsion Injuries

Loss of sensory impulses to the spinal cord constant pain that is central in origin is felt in the dermatome root.

Clinical Characters

1. Pain begins 2 to 3 weeks after injury.

2. Constant burning pain (arm is on fire) or arm is hit repeatedly with hammer or sudden, sharp, electric shock like shooting pain, high in few seconds and gradually comes as burning pain.

3. Pain 2 - 3 times per day.

4. During the time of intense pain, patient may stop talking, takes his breath away grip his arm.

5. Difficulty of sleep.

6. Cold, illness, emotional stress, aggravating the pain.

Investigations

1. Electrodiagnostic Test

• Provide information to confirm denervation.

• Diagnose the nature of lesion, whether pre-ganglionic (avulsion) or post-ganglionic.

2. Electromyography (EMG)

a. Presence of small fibrillation protentials or large fibrillation potentials called sharp positive waves at rest indicate wallarian denervation.

b. Needle EMG is appropriate in determining whether root avulsion has occurred, e.g. limb muscle is denervated but erector spinae at corresponding functioning normally indicate post-ganglionic lesion.

Brachial Neuralgia 43

c. Polyphasic unit indicates regeneration but clinical evidence takes many weeks.

3. Sensory action potential (SAP) Detection of either reduced or normal amplitude sensory action potentials with absence of motor conduction, in a flail and anaesthetic limb indicates that the nerve is in continuity with its cell body with lesion being present proximal to the dorsal root ganglion indicates avulsion of root (pre-ganglionic). Negative sign indicates lesion to the dorsal root ganglion with an intact root post-ganglionic.

4. Somatosensory evoked potentials Provides information about the various pathways and conditions of intraspinal roots. If root is avulsed, evoked potential will not be obtained because of lack of central connection even though the sensory peripheral nerve conduction may be normal.

Nerve Conduction Velocity

Normal conduction indicates intact conductivity. When not measurable indicates the severance of nerve root fibers with wallerian degeneration. Both the techniques of motor and sensory nerve conduction velocities should be done to distinguish root avulsion from distal ruptures.

Myelogram

Myelography with radio-opaque dye will show “meningocele” in the presence of root avulsion.

CT Scan and Magnetic Resonance Imaging

CT scan help to display any spinal fracture and its impact on the spinal root. MRI makes use of magnetic properties of atomic nuclei that indicates any spinal cord lesions and root avulsion in a better way (Fig. 5.1).

IV. THORACIC OUTLET SYNDROME (TOS)

Narrow upper end of thorax which is continuous with neck that is sterno costo vertebral spaces.

44 Treatment of Neck and Back Pain

44 Treatment of Neck and Back Pain Fig. 5.1: MRI Boundries Anterior : Upper border of

Fig. 5.1: MRI

Boundries

Anterior

:

Upper border of Manubrium Sterni

Posterior

:

Superior surface of body of first vertebra

Laterally

:

First rib with its cartilage.

There are many important structures passing through the inlet namely,

• Trachea

• Esophagus

Lung

Thymus

Arteries

Nerves

Arteries

• Left common carotid artery

• Left subclavion artery

• Brachiocephalic artery and vein

Nerves

• Phrenic nerve

• Vagus nerve

Brachial Neuralgia 45

• Sympathetic trunk

• C 8 and T 1 trunk of brachial plexus The compression syndrome of upper thoracic outlet (inlet) syndrome was first described by Thorburn in 1905. It is a neuro- vascular compression syndrome comprises:

• Cervical rib

• Anterior scalene syndrome

• Costo clavicular syndrome

• Pectoralis minor syndrome

a. Cervical Rib

This is a congenital condition characterized by an extra rib arising from seventh cervical vertebra. Commonly present in right side.

Types

Complete: Completely bony rib from C 7 vertebra. Bulbous end: Here anteriorly forms a bulbous end. Tapering: Anteriorly fibrous and tapers. Fibrous band: Transverse process of C 7 vertebra is enlarged and connected to first rib.

Pathology

Increased angulation causes stretching of brachial plexus over the cervical rib or anterior scalene compress the nerve against the cervical rib.

Subclavian artery arches over the cervical rib, stretched beyond this point leads to stenosis. This becomes thrombus formation, later this may emobolise causing digital gangrene.

Predisposing Factors

• Loss of tone in shoulder girdle muscles

• Traction due to carrying heavy weight

• Drooping of shoulder girdle after thoracoplasty

Clinical Features

• Pain, paresthesia—tingling sensation or numbness down medial aspect of forearm and hand.

• Sensory anaesthesia over the lower trunk of brachial plexus.

46 Treatment of Neck and Back Pain

Muscle wasting in T 1 distribution—small part of hand.

Tendency to drop things.

Inability to perform small repetitive finger movements like winding a watch, buttons.

Horner’s syndrome may be observed.

Pain worse at night, pain increased by turning the head towards the unaffected side and downward traction of shoulder.

Tender of scalenus muscle.

b.

Pectoralis Minor Syndrome

Muscle originate from 3rd, 4th, and 5th ribs inserted into the coracoid process of scapula. Compression due to repetitive movements of the arms above the head. Shoulder elevation and hyper-abduction.

c. Claviculo Costal Syndrome

Compression of neurovascular bundle beneath the clavicle at first rib causes group of symptoms termed claviculo costal syndrome.

Predisposing Factors

Fatigue, anxiety, depression, poor posture-drooping of heat at shoulder causes reduce space between clavicle and first rib causing compression of structures. In middle aged women, medial side of clavicle is lower than men. So reduce the clavicle and first rib space reduced. Scapula ptosis is greater in female with large breast due to attchment of pectoralis major muscles.

d. Anterior Scalenus Syndrome

Muscles originate from transverse process of C 3 to C 6 vertebra, insert in upper surface of the first rib. Brachial plexus and subclavian artery passes over the first rib, posterior to scalenus anterior. Strenuous physical activity, anxiety, tension, hyper-extension, injuries causes spasm of the muscles. Deep breathing in turning the head compressing the bundle.

Clinical Features

• Numbness, tingling sensation in forearm, hand and digits.

• Pin and needles of heads and fingers.

Brachial Neuralgia 47

• Weakness of hand muscles.

• Sleep disturbed due to pain.

• Dull deep vague aching type pain.

e. Neurological Amyotrophy (Brachial Neuritis or Parsonage—Turner Syndrome)

Condition characterized by severe pain in the shoulder and neck followed by weakness of upper limb muscles.

Aetiology

1. Viral infection—Cytomegalovirus

2. Serum sickness or inoculation with tetanus toxoid

3. Interavenous injection

Clinical Features

• Sudden onset of severe pain followed by muscle weakness

• Muscle wasting like supraspinatus, deltoid, serratus anterior, trapezius, triceps, biceps, diaphragmatic muscles, forearm muscles, especially flexor pollicis longus weakness.

• Sensory loss over deltoid, radial aspect

• Reflex loss in biceps, triceps

• Arm is maintained in flexion and adduction at shoulder to minimize traction in brachial plexus.

Investigation

• Viral titres positive.

• CSF shows mild protein rise and pleocytosis.

• Electrophysiological studies shows involvement in upper limb nerves.

• Nerve conduction studies shows slowing the conduction of the affected nerves after 7 to 10 days.

• EMG shows fibrillation and positive sharp waves.

Prognosis

• Pain stop in few days to 3 weeks

• Motor function is good

• Full recovery achieved only 2 to 3 years.

48 Treatment of Neck and Back Pain

V. BRACHIAL NEURALGIA ASSESSMENT

Subjective Examination

Name, Age, Sex, Diagnosis. Chief Complaints: Foremost difficulties and disabilities.

Behaviour of Symptoms

• When the pain started.

• Type of pain.

• State of pain.

• Radiating or localized.

• Constant or intermittent.

• Any predisposing injury

• Aggravating and relieving factors

Pain Assessment Scales

I. Visual Analogue Scale

Patient is asked to record the severity on a 10 centimeter line with anchors of “no pain” and worse pain at either ends.

0 1 2 3 4 5 6 7 8 9 10 No Severe pain pain
0
1
2
3
4
5
6
7
8
9
10
No
Severe
pain
pain

Record each session before and after the treatment. Note: Always open ended structured question to rule out nature of pain.

II. Simple Descriptive Scale

Verbal Scale Ask the patient to pick a word that reflect the intensity of the pain from a list of words or words spaced along horizontal or vertical line.

of words or words spaced along horizontal or vertical line. No pain Mild Moderate Severe Very
of words or words spaced along horizontal or vertical line. No pain Mild Moderate Severe Very
of words or words spaced along horizontal or vertical line. No pain Mild Moderate Severe Very
of words or words spaced along horizontal or vertical line. No pain Mild Moderate Severe Very
of words or words spaced along horizontal or vertical line. No pain Mild Moderate Severe Very

No pain

Mild

Moderate

Severe

Very

severe

Worst

pain

III. Numerical Scale

Patient has to pick a number from 0 to 10 that represents his pain. 0 means no pain and 10 means worst pain.

Brachial Neuralgia 49

0 1 2 3 4 5 6 7 8 9 10 No pain Moderate Worst
0
1
2
3
4
5
6
7
8
9
10
No pain
Moderate
Worst pain

IV. Submaximal Effort Tourniquet Test

Blood pressure cuff over the arm, inflate the cuff, ask the patient to rhythmically clench and unclench grip his hand. As the hand becomes progressively ischemic, ask him to match this ischemic pain to actual pain felt.

V. Somatic Differential Scale

MC GILL Pain Questionnaire Word lists and categories that represent various aspect of pain experience. Give the list to the patient, ask to select from these lists, words that best describe his present experience of part.

VI. Spatial Distribution of Pain Exam

Give body diagram for marking the location and nature of pain intensity. Ask to mark the type, location and nature of pain.

M shooting pain, pin and needle sharp pain.

Objective Examination

Observation

1. Posture Sitting and standing. Observe any deviation in the neck, drooping shoulder.

2. Attitude of Limb Position in arm is held whether abducted or adducted.

3. Soft Tissue Analysis Skin condition: Colour change, scar. Swelling: Digits, forearm, arm. Erythema: Cervical, upper limb.

4. Muscle Bulk Check wasting of arm, forearm, hand.

50 Treatment of Neck and Back Pain

Present Medical History Need to Consider

• Onset of symptoms

• X-ray, CT scan, MRI, Discography, EMG

• Earlier attack

• Treatment modality use.

Past Medical History

Hobbies and habits like smoking, alcoholic, knittry, sewing, forceful game. Number of pillows uses while sleeping.

On Examination

Measure Range of Motion

 

Movements

Range

 

Flexion

0 - 45 Degree

Cervical

Extension

0 - 45 Degree

Lateral flexion

0 - 40 Degree

Rotation

0 - 45 Degree

Flexion

0 - 90 Degree

Extension

0 - 45 Degree

Abduction

0 - 180 Degree

Adduction

Shoulder

Internal

0 - 70 Degree

Rotation

External

0 - 90 Degree

Rotation

Manual Muscle Testing

Based on MRC Grading

• Neck flexors, lateral flexors, extension

• Deltoid

• Biceps

• Wrist extensors and flexors

• Finger and thumb.

Brachial Neuralgia 51

Palpation

Warmth

Check temperature by dorsum of the examiner hand and compare the normal side.

Muscle Spasm

Protective muscle spasm of neck muscles and upper limb.

Skin Moisture

Tenderness

Over the bone, ligament, muscles and tendon.

Sensory Deficit

Parathesia, hyperthesia and anaesthesia.

Reflexes

Biceps Jerk (C 5 )

Arm is relaxed, slightly flexed, palpate the biceps tendon with thumb and strike with tendon hammer. Response: Elbow flexion and biceps contraction.

Brachioradialis Jerk (C 6 )

Strike lower end of radialis. Response: Elbow and finger flexion.

Triceps Jerk (C 7 ):

Strike few inches above the olecranon process. Response: Elbow extension and triceps contraction.

Grading of Reflexes

O

-

Absent

1+

-

Tone is slightly changed. transient with no movement of extremities

2+

-

Visible movement of extremities

52 Treatment of Neck and Back Pain

4+

-

Oscillatory and sustained movement which lasts for more than 30 seconds also known as clonus.

Sensations

Mark on body chart for numbness and tingling. Exact site and location of radiating pain. Touch sensation by scratching by pin and cotton wool.

Special Test

Spurling Neck Compression Test

Patient is seated; head laterally flexed and rotated to the side of the pain, axial compression is exerted downward upon the head. This test reproduces the symptoms. This test closes the foramina on the side towards which pain is felt. Downward compression further closes the foramen and compress the disc thus increasing its protrusion and increases the impingement of the osteophytes up in the nerve roots.

Axial Manual Traction or Distraction Test

Traction manually disappears or diminishes the symptoms result is positive indicates nerve root compression. Patient should be in the sitting position.

Arm Abduction Test

Patient in sitting position, elevate the affected arm and apply traction to it. Relief of radiating pain indicates brachial plexus etiology.

Adson or Scalene Maneuver

Patient in sitting position, examiner locate the radial pulse. Patient rotates either head towards the tested arm and less the head tilt backwards or extend the neck while examiner extends the patient arm. Result: Disappearance of pulse indicates positive test of Thoracic Outlet Syndrome etiology.

Allen Test

Patient sitting position, examiner flexes the patient elbow to 90 degree while shoulder is extended horizontally and laterally rotated.

Brachial Neuralgia 53

Patient is asked to turn their head away from the tested arm. Radial pulse is palpated and if it is disappeared as the patient’s head is rotated to the test is considered as positive.

Hanch-UP or East Test

Patient brings their arms up with elbows slightly behind the head. Now patient opens and closes their hands slowly for 3 minutes. Result: Positive test indicated by pain, heaviness or arm weakness numbness and tingling of head.

Costo-Clavicular Maneuver

Patient in sitting position, examiner located the radial pulse and draws the patient’s shoulder down and back as the patient lifts their chest in exaggerated “Attention” posture. Positive test indicated by absence of pulse complain symptoms.

Provocative Elevation Test

Patient in sitting position, performed on patient who already present with the symptoms. Patient is seated. Patient has to cross the upper limb with flexed elbow in front of the chest. Passively shoulders are elevated forward and into full elevation. Maintain their position for 30 seconds or more. Increased pulse, skin colour change increased hand temperature, signs of numbness by pin and needles.

Assessment for Brachial Plexus Lesions

Same general assessment as early. In addition to that include the following:

Subjective

Mechanism of Injury

According to Frampton it is divided into 2 types:

High speed, large impact injuries—preganglionic plexus injury, e.g. RTA. Low speed, small impact injuries—postganglionic plexus injury, e.g. roll down a staircase.

Objective

Observation in front, side and behind.

54 Treatment of Neck and Back Pain

Muscle Atrophy

• Upper Quarter

• Wing of Scapula

• Supraspinatus

• Infraspinatus

• Deltoid

Side View—Forward

• Head posture

• Kyphosis

• Protrusion

• Elevation of scapula

Front

• Attitude of Limb

• Constriction of Pupils (or) Ptosis (indicates Horner’s syndrome).

Passive Range of Motion Test

Assess all the joint in upper limb. Note contraction of:

Shoulder