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 priciple of treatment from a rehabilitative perspective 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 priciple of treatment from a rehabilitative perspective

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 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 Cervical radicular pain: pain involving the shoulder girdle and distally, in the upper limb General prevalence from 9-18% General prevalence from 9-18% Increases with age Increases with age Radiculopathy: Annual incidence of 83.2/10000 and with peaks at 50-54 years of age for radiculopathy Radiculopathy: Annual incidence of 83.2/10000 and with peaks at 50-54 years of age for radiculopathy

4. Pathophysiology of cervical pain and the significance of referral patterns 7 vertebrae and 8 roots 7 vertebrae and 8 roots C0-1: 10° of flexion and 25° of extension C0-1: 10° of flexion and 25° of extension C1-2: responsible for 40-50% off all cervical axial rotation; 45° in all direction C1-2: responsible for 40-50% off all cervical axial rotation; 45° in all direction Functional anatomy of the joints, discs, roots and other related ones Functional anatomy of the joints, discs, roots and other related ones Dermatomes and areas of radicular pain Dermatomes and areas of radicular pain Disc herniations and degenerations Disc herniations and degenerations Injury Injury

8. Common Clinical Disorders

9. Definition of Cervical strain and sprains Strain: a musculotendinous injury produced by an overload injury due to excessive forces imposed on the cervical spines Strain: a musculotendinous injury produced by an overload injury due to excessive forces imposed on the cervical spines Sprain: overstretching or tearing injuries of spinal ligaments Sprain: overstretching or tearing injuries of spinal ligaments

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

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

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

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

19. Shockwave therapy During Shockwave therapy, a high- intensity sound wave interacts with the tissues of the body 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 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 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. As the injured area is returned to normal, functionality is restored and pain is relieved.

20. Platelet rich plasma injection therapy

21. Cervical radiculopathy and radicular pain

22. 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

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

25. Intervertebral discs are located between the vertebral bodies of C2-C7 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 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 The intervertebral discs are thicker anteriorly and therefore contribute to normal cervical lordosis

26. The foramina are largest at C2-C3 and progressively decrease in size to the C6-C7 level 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 nerve root occupies 25-33% of the foraminal space The neural foramen is bordered anteromedially by the 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 The neural foramen is bordered anteromedially by the 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 The nerve roots exit above their correspondingly numbered vertebral body from C2-C7. C1 exits between the occiput and atlas, and C8 exits below the C7 vertebral body The nerve roots exit above their correspondingly numbered vertebral body from C2-C7. C1 exits between the occiput and atlas, and C8 exits below the C7 vertebral body

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

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

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

31. 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 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. 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.

32. TRACTION Continuous VS intermittent Continuous VS intermittent Home cervical traction units may decrease radicular symptoms. 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 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 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 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 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

35. PHYSICAL THERAPY AND MANIPULATION restoring range of motion and overall conditioning of the neck musculature 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 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 As the pain improves, a gradual, isometric strengthening program may be initiated with progression to active range-of-motion and resistive exercises as tolerated

38. Myofacial Pain Dysfunction Syndrome (MPDS)

39. Terminology: muscle pain versus myofascial pain Muscle pain: widespread, aching pain that appears to emanate from muscles together with tenderness over the muscles 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 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

40. regionalized aching and poorly localized pain in the muscles and joints regionalized aching and poorly localized pain in the muscles and joints sensory disturbances, such as numbness in a characteristic of distribution sensory disturbances, such as numbness in a characteristic of distribution the type of pain felt is characteristic of the muscle involved 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), whilechronic pain may result from poor posture or overuse 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 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. They may or may not be aware of muscle weakness in the affected muscles and may have a tendency to drop things.

43. Trigger points focal point tenderness focal point tenderness reproduction of pain upon trigger point palpation reproduction of pain upon trigger point palpation hardening of the muscle upon trigger point palpation (taut band) 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 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 Slow twitch response

44. End plate

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

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

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

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

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