_________________________________________________________________________ Neck Pain in Adults
Vertebral artery dissection caused by high-velocity, low- amplitude thrusting is a rare but recognized outcome. Vascular accidents following extension and rotation of the neck beyond the physiologic range lead to a cascade of events including thrombosis, stroke, and death [226]. More than 400 cases following cervical manipulation have described arterial dissection, brain stem injury, cerebellar injury, spinal cord injury, thrombosis, locked-in syndrome, joint dislocation, and death. Risk of these rare but catastrophic events can be minimized by avoiding extension-based high-velocity, low- amplitude thrust [16]. Joint Mobilization Joint mobilization techniques incorporate a low-velocity and small- or large-amplitude oscillatory movement, within a joint’s passive range of motion [8]. A mobilization treatment consists of passive movement involving oscillatory motions to the vertebral segment(s). The passive mobility is performed in a graded manner (I, II, III, IV, or V), which depicts the speed and depth of joint motion during the maneuver. Mobilization may include skilled manual joint tissue stretching [103]. Other modalities include myofascial releases, counterstrain, and indirect or direct muscle energy techniques [16]. Indications include the need to improve joint play, segmental alignment, or intracapsular arthrokinematics or to reduce pain associated with tissue impingement. Mobilization should be accompanied by active therapy [103]. A 2015 Cochrane review of mobilization therapy in neck pain noted anterior-posterior mobilization may favor pain reduction over rotatory or transverse mobilizations at immediate follow-up in patients with acute and subacute neck pain [225]. For those with subacute and chronic neck pain, cervical mobilization alone may not be different from ultrasound, TENS, acupuncture, and massage in improving pain, function, quality of life, and participant satisfaction at immediate and intermediate follow-up. Multiple sessions of TMD manual therapy may be more effective than cervical mobilization in improving pain/function at immediate and intermediate follow-up for patients with chronic cervical headache and TMD. For grade V mobilization, contraindications include joint instability, fracture, severe osteoporosis, infection, metastatic cancer, active inflammatory arthritides, and signs of progressive neurologic deficits, myelopathy, vertebrobasilar insufficiency, or carotid artery disease. Relative contraindications include stenosis, spondylosis, and disk herniation [103]. Manipulation and Joint Mobilization Co-Therapy Manipulation and mobilization show similar results on most outcomes. In acute and chronic neck pain, manipulation and cervical mobilization produced similar changes in pain, function, quality of life, global perceived effect, and patient satisfaction at immediate-, short-, and intermediate-term follow-up [225].
Outcomes with gentle mobilization were superior to physical therapy and comparable to high-velocity, low-amplitude thrust [225]. For mechanical neck disorders, manipulation or mobilization were more beneficial combined with exercise than as monotherapy [16]. Short-term improvement is documented in acute whiplash pain, cervicogenic headache, and radiculopathy secondary to disk herniation, but others conclude that mobilization or manipulation in patients with radicular findings has insufficient evidential support [16; 51]. No evidence exists that manipulation confers long-term benefit, improves chronic conditions, or alters the natural course of a neck pain disorder [16]. MECHANICAL AND MANUAL TRACTION Manual or mechanically assisted traction applies an intermittent or continuous distractive force to the cervical spine. Distraction refers to gentle pulling of the head upward to relieve pressure and compression of joints or nerve roots in the cervical spine [8]. Traction is initiated manually by a physiotherapist or as a component of manipulation or mobilization treatment. The usual course of treatment is two to three times per week for four weeks. Patients who benefit from manual traction should continue with a home cervical traction unit [103]. Traction regimens may be heavy weight-intermittent or light weight-continuous. The neck is flexed 15–20 degrees (i.e., not extended) during traction. In the cervical spine, 10 pounds of force is necessary to counter gravity and 25 pounds of force is needed to achieve separation of posterior vertebral segments. Light weight-continuous home traction is cost-effective and provides greater autonomy to the patient. Pneumatic traction devices afford greater patient comfort, which can increase treatment adherence [51]. Traction is popular among patients with cervical radiculopathy, but it is contraindicated with tumor, infection, fracture, or dislocation [103]. Mechanical traction is widely used to promote cervical immobilization and widen the foraminal openings. Cervical traction may relieve radicular pain from nerve root compression, but it does not improve pain from soft-tissue injury. Hot packs, massage, or electrical stimulation should be applied before traction to relieve pain and relax muscles [65]. IMMOBILIZATION Immobilization limits neck motion to reduce nerve or soft tissue irritation, and soft cervical collars are the most widely used device. For acute soft-tissue neck injuries, cervical collar use should not exceed three to four consecutive days to avoid risks of losing cervical range of motion and neck strength from muscle disuse and atrophy [51].
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