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

2. Objectives of this lecture
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
Origins of pain/discomfort in neck region: bone, soft tissues, vessels, nerves and so forth

3. Introduction and epidemiology
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 years of age for radiculopathy

7. 7 vertebrae and 8 roots
C0-1: 10° of flexion and 25° of extension
C1-2: responsible for 40-50% off all cervical axial rotation; 45° in all direction

9. 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
Sprain: overstretching or tearing injuries of spinal ligaments
grading

12. Epidemiology of Cervical strain and sprains
85% of neck pain results from acute, repetitive or chronic injuries
Most common cause of neck pain in non-catastrophic sports injuries

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

16. The most common lesions affecting the cervical spine following whiplash injury

17. Diagnosis of Cervical strain and sprains
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

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

23. Shockwave therapy
During Shockwave therapy, a high-intensity sound wave interacts with the tissues of the body
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
Stimulation of these biological mechanisms creates an optimal healing environment
As the injured area is returned to normal, functionality is restored and pain is relieved.

25. Platelet rich plasma injection therapy

26. Cervical radiculopathy and radicular pain

27. Definition of Cervical radiculopathy and radicular pain
A pathologic process involving neurophysiologic dysfunction of the nerve root
The seventh (C7; 60%) and sixth (C6; 25%) cervical nerve roots are the most commonly affected

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

29. Cervical intervertebral disc herniations

30. Intervertebral discs are located between the vertebral bodies of C2-C7
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

31. The foramina are largest at C2-C3 and progressively decrease in size to the C6-C7 level
The nerve root occupies 25-33% of the foraminal space
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

32. Degeneration of the spines

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

34. Cervical radicular pain patterns

35. Referred pain patterns of cervical facet joints

40. Red flags !!
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

41. Cervical astrocytoma
metastasis

42. C1-2 subluxation/dislocation

43. Compression fracture

44. spondylolsithesis

45. Ankylosing spondylitis/SpA/rheumatoid spondylitis/spondyloarthropathy: bamboo spine

46. Infectious spondylodiscitis: radiographies

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

48. Target zones for nerve block

49. IMMOBILIZATION
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.

50. TRACTION 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

55. PHYSICAL THERAPY AND MANIPULATION
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

58. Myofacial Pain Dysfunction Syndrome (MPDS)

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

60. 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.

63. Trigger points 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

64. End plate

66. Management of MPDS 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

67. Management of MPDS
Anti-depressants (primarilySNRiIs), 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

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

69. Dry needling injection
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

70. Thank you for your attention. Any questions or thoughts?