Cervical Spine Impairments Research Articles

Bridging the gap between temporomandibular disorders, static balance impairment and cervicogenic dizziness: Posturographic and clinical outcomes

Several studies have investigated the possible influence of temporomandibular disorders (TMD) on body posture and whether cervical spine disorders, such as cervicogenic dizziness (CGD) could play an additional role in affecting static balance. The purpose of this study was to analyze static postural behavior by means of static posturography, in patients affected by either TMD or CGD alone or by both conditions, and to compare findings with a group of healthy subjects. Significant changes in posturographic parameters were found among the three groups of patients and when compared with controls. When the three study groups were compared to each other, subjects affected by a combination of TMD and CGD showed worse postural performances with respect to subjects affected by CGD or TMD alone. Correlations with self-perceived dizziness, anxiety, depression and jaw functionality, investigated by means of validated questionnaires, were found among all patient groups. These results provide new evidences for the presence of static balance alterations in patients suffering from TMD with and without associated cervical spine impairment, by using a reliable diagnostic technique. Further studies are needed in order to identify any causal relation between these two disorders.

Q&A: Converting Cervical Spine Rating to Back Rating

QUESTION: I practice in South Carolina and have been asked to convert an impairment rating (IR) of the cervical spine to a percentage loss of the back. South Carolina Title 42-Workers’ Compensation, Section 42-9-30, provides a listing “for the loss of use of the back.” However, it does not provide one for the cervical spine. How do I make that conversion?ANSWER: The spine is comprised of three segments: the cervical spine (neck), the thoracic spine (upper and mid back), and the lumbar spine (lower back). The AMA Guides’ cervical spine IR was never intended to be converted to “a percentage loss of the back.” To do so is medically nonsensical because the neck (cervical spine) and back (thoracolumbar spine) are two anatomically different entities. Similarly, being asked to convert a cervical spine impairment to a “head” impairment makes no sense, as no edition of the AMA Guides has ever used a concept of “head” impairment.If a law or regulation requires such a nonsensical conversion, it is far preferable to have some justifiable and defensible method for doing so rather than pulling a number out of thin air. South Carolina has a state schedule of disabilities; unscheduled disabilities may be determined using the AMA Guides (edition unspecified) or other accepted medical authority. However, many physicians in South Carolina use the AMA Guides, and the ratings based thereon are generally accepted.Regarding the diagnosis-related estimate (DRE) and range of motion (ROM) methods for rating spinal impairments, the AMA Guides, Fifth Edition, Section 15.13, Criteria for Converting Whole Person Impairment to Regional Spine Impairment (5th ed, 427), states: “Under the DRE method, a whole person estimate being converted to a regional estimate would be divided by 0.35 for the cervical spine, 0.20 for the thoracic spine, and 0.75 for the lumbar and sacral spines. Under the ROM method, a whole person estimate being converted to a regional estimate should be divided by 0.80 for the cervical spine, 0.40 for the thoracic spine, or 0.90 for the lumbosacral spine (Figure 15-19).”Regarding diagnosis-based impairment (DBI), the subsection on regional impairment in the AMA Guides, Sixth Edition (6th ed, 583) states that the “conversion factors used in the DBI method are the same as those used for the DRE method in the Fifth Edition…0.35 for the cervical spine, 0.20 for the thoracic spine, and 0.75 for the lumbar spine.”Assume you used the DRE method from the Fifth Edition or a DBI from the Sixth Edition and came up with 10% whole person impairment (WPI) due to the cervical spine pathology. To convert this to a back rating, does one divide by 0.20, 0.75, or an average of the two numbers? Because both thoracic and lumbar spine comprise the back, rather than picking one or the other, it seems more defensible to average the two numbers, ie, the mean being 0.475: 10% ÷ 0.475 = 21%. Hence, while medically very dubious, if such a conversion is required by law or regulation, 10% WPI for cervical spine pathology could be converted to 21% “loss of the back.”While the aforementioned method provides a percentage in an attempt to comply with state law or regulation, the adjudicator will ultimately decide what the law intended with the requirement to convert a cervical spine rating to a “percentage loss of the back.”

Association of cervical spine signs and symptoms with temporomandibular disorders in adults: a systematic review protocol.

The objective of this systematic review is to assess the evidence of association of cervical spine signs and symptoms with temporomandibular disorders (TMD). This will help to lend credence to mechanisms supporting the association in order to improve care strategies for this condition. The association of cervical spine impairments (in relation to neck posture, cervical spine mobility, muscle tenderness, muscle activity, and neck disability) with TMD has been widely discussed in the literature. Clarification of this relationship is important for health professionals to better assess and treat TMD. Eligible studies will include participants aged 18 years and over, with a diagnosis of TMD from the Research and Diagnostic Criteria for Temporomandibular Disorders or a revised version. Exclusion criteria will be participants with previous temporomandibular joint surgery, history of trauma or fracture in the temporomandibular joint or the craniomandibular system; serious comorbid conditions such as cancer, rheumatic disease, and neurological problems; primary cervical spine disorders such as disc herniation or spinal degenerative changes; or systemic disease such as ankylosing spondylitis. The search for articles will be conducted in the databases PubMed, PEDro, CINAHL, Web of Science, and Embase, without language or time restrictions. Two independent reviewers will review the title, abstract, and full texts of identified studies; select studies against the inclusion criteria; assess the methodological quality of eligible studies using critical appraisal tools; and perform data extraction. Relevant quantitative data will be pooled with statistical meta-analysis, when possible. PROSPERO CRD42019123698.

Bruxism, temporomandibular dysfunction and cervical impairments in females – Results from an observational study

PurposeBruxism is highly prevalent and defined as abnormal habitual mouth activity including clenching of the teeth and increased jaw muscle activity. The association between bruxism and temporomandibular dysfunction (TMD) is debated, in particular the association between cervical spine impairments, bruxism, and TMD. Hence the purpose of this study was to identify the relationship between bruxism, TMD, and cervical spine impairments. MethodsThis observational study categorized 55 female volunteers suitable for evaluation to a bruxism (n = 33) or non-bruxism group (n = 22) based on comprehensive screening using questionnaires and visual observation of the mouth by 2 independent dentists. Following this, both groups were evaluated for TMD, severity and location of head/neck pain, neck disability index (NDI), cervical spine impairments, and tissue mechanosensitivity. Regression analysis was used to evaluate the relationship between bruxism, TMD severity, and cervical impairments. ResultsCoefficients of pain and bruxism were significantly associated with NDI scores (0.43, p < 0.001; 3.24, p = 0.01) with large and medium sized effects. As a consequence, both severity of TMD and bruxism status are independently associated with cervical impairments. Having TMD is an independent predictor for head/neck pain and cervical impairments. Pain associated with movement tests and tissue mechanosensitivity was found to be an important factor in bruxism. ConclusionClinicians need to be aware that signs of cervical movement impairment are not likely to be associated with bruxism, rather they should focus on improving orofacial function and tissue mechanosensitivity.

Headache symptom modification: the relevance of appropriate manual therapy assessment and management of a patient with features of migraine and cervicogenic headache – a case report

ABSTRACT Objectives People who suffer from headache frequently present with multiple headache forms and the precise diagnosis of the dominant headache form can be challenging. This case report describes a headache symptom modification approach in the diagnosis and management of a patient presenting with combined features of chronic migraine and cervicogenic headache (CGH). Methods A 28-year-old female presented with combined features of chronic migraine and CGH diagnosed according to guidelines published by the International Headache Society. Her main complaints were frequent and severe headache along with frequent neck pain and disability. Symptom modification based on the Mulligan Concept was utilized for assessment of musculoskeletal dysfunction associated with headache which identified upper cervical articular impairment. Impairments were also identified in craniocervical muscle control and endurance. Interventions comprised six sessions of Mulligan manual therapy to address cervical spine impairments, exercise for craniocervical control and endurance, as well as patient education. Results Headache frequency at 6 months follow up was reduced from 16 to 3 days per month and intensity from 72 to 23 on Visual Analogue Scale. Clinically relevant improvements were also found in headache duration, pressure pain thresholds, medication intake and Headache Activities of Daily Living Index post-treatment and continued up to 6 months follow-up without adverse events. Discussion This case report illustrates the use of a manual therapy symptom modification approach in the management of headache. Improvement in headache symptoms and disability suggests that the musculoskeletal impairments and headache symptoms were more a feature of CGH rather than migraine. The mechanisms underlying these changes in symptoms and impairments are discussed.

CHARACTERIZATION OF CERVICAL SPINE IMPAIRMENTS IN CHILDREN AND ADOLESCENTS POST-CONCUSSION

Patients with concussion may present with cervical spine impairments, therefore accurate characterization of cervical post-concussion impairments is needed to develop targeted physical therapy interventions. To characterize the type, frequency and severity of cervical impairments in children and adolescents referred for physical therapy after concussion.Study design: Retrospective, descriptive study. A retrospective analysis was conducted for 73 consecutive children and adolescents who received cervical physical therapy following a concussion. Data was classified into six broad categories. The frequency and intensity of cervical impairments within and across the categories was reported. Ninety percent of patients demonstrated impairments in at least three out of five assessment categories whereas 55% demonstrated impairments in at least four out five assessment categories. Of the five assessment categories, posture (99%) and myofascial impairment (98%) demonstrated highest impairment frequency followed by joint mobility (86%) and muscle strength (62%). Cervical joint proprioception was the least commonly evaluated assessment category. High prevalence of cervical spine impairments was observed in the subjects included in this study with muscle tension, joint mobility, and muscle strength being most commonly affected. The categories of impairments examined in this cohort were consistent with the recommendations of the most recent clinical practice guidelines for neck pain. This study provides preliminary data to support the framework for a cervical spine evaluation tool in children and adolescents following concussion. Level 4.

Upper cervical range of motion is impaired in patients with temporomandibular disorders

Aims:Clinicians increasingly suggest assessment and treatment of the cervical spine in patients with temporomandibular dysfunction (TMD); however, few studies have investigated upper cervical spine mobility in people who suffer from TMD. The purpose of this study was to investigate whether patients with TMD pain (with or without headache) present with upper cervical spine impairment when compared with asymptomatic subjects.Methodology:A single blind examiner evaluated cervical range of motion (ROM) measures including axial rotation during the flexion–rotation test (FRT) and sagittal plane ROM. Twenty asymptomatic subjects were compared with 37 subjects with pain attributed to TMD, confirmed by the Revised Research Diagnostic Criteria. Subjects with TMD were divided according to the presence of headache (26 without headache TMDNHA, 11 with headache TMDHA). One-way analysis of variance and planned orthogonal comparisons were used to determine differences in cervical mobility between groups. All subjects with TMD were positive on the FRT with restricted ROM, while none were in the control group.Results:The analysis of variance revealed significant differences between groups for the FRT F(2,54) = 57·96, P<0·001) and for sagittal ROM [F(2,54) = 5·69, P = 0·006]. Findings show that the TMDHA group had less axial rotation than group TMDNHA, and both TMD groups had less ROM than controls. For sagittal ROM, the only difference was between group TMDHA and controls.Conclusions:Subjects with TMD had signs of upper cervical spine movement impairment, greater in those with headache. Only subjects with TMD and headache had impairment of cervical spine sagittal plane mobility. This study provides evidence for the importance of examination of upper cervical mobility determined by the FRT in patients who suffer from TMD.

The Relationship between Cervicogenic Headache and Impairment Determined by the Flexion-Rotation Test

Objective This study evaluates the association between probable cervicogenic headache (CGH) and associated headache symptoms and cervical spine impairment identified by the flexion-rotation test (FRT). Methods This was an observational study. Ninety-two subjects were evaluated, 72 with probable CGH and 20 who were asymptomatic. Headache symptoms were evaluated by questionnaire. A single blind examiner conducted the FRT, reporting the test state (positive or negative) before measuring range of motion (ROM). Fifteen subjects reported headache during testing and were subsequently retested when pain-free. A paired t test was used to determine whether FRT mobility to the most restricted side differed when the subject was experiencing headache. Univariate linear regression analysis and multiple regression analysis were used to examine the relationship between subject and headache characteristics, and range of motion during the FRT. Logistic regression analysis was used to examine relationships between subject and headache characteristics and whether the FRT was positive or negative. Results Mean ROM was significantly reduced ( P < .01) by 6° in the presence of headache, but this did not influence test interpretation. Regression analysis revealed that half the variance in FRT ROM was explained by an index of headache severity or component parts but not by other headache characteristics. Conclusions These findings indicate a relationship between cervical movement impairment and the presence and severity of CGH.

Letter to the Editor: Management of Whiplash-Associated Disorder Addressing Thoracic and Cervical Spine Impairments: A Case Report

Letter to the Editor: Management of Whiplash-Associated Disorder Addressing Thoracic and Cervical Spine Impairments: A Case Report

March 2005 Letter to the Editor-in-Chief

Letter to the Editor-in-Chief of JOSPT as follows: ‘Management of Whiplash-Associated Disorder Addressing Thoracic and Cervical Spine Impairments: A Case Report’ J Orthop Sports Phys Ther 2005;35(3):181. doi:10.2519/jospt.2005.35.3.181

Management of Whiplash-Associated Disorder Addressing Thoracic and Cervical Spine Impairments: A Case Report

Management of Whiplash-Associated Disorder Addressing Thoracic and Cervical Spine Impairments: A Case Report

Management of Whiplash-Associated Disorder Addressing Thoracic and Cervical Spine Impairments: A Case Report

Clinical case report. To describe a physical therapy program addressing impairments of the upper thoracic and cervical spine region for an individual with a whiplash-associated disorder. A 32-year-old female with complaint of diffuse posterior cervical and upper thoracic region pain was evaluated 2 weeks following a motor vehicle accident. The patient reported that she was unable to sit for longer than 10 minutes or perform household duties for longer than 1 hour. In addition, she was unable to perform her tasks as a postal worker or participate in her customary running and aerobic exercise activities because of pain in the cervical and upper thoracic region. An examination for physical impairments was performed, including the measurement of cervical range of motion using the CROM device, and the assessment of soft tissue and segmental mobility of the upper thoracic and cervical spine regions. The Northwick Park Neck Pain Questionnaire was used to assess functional limitations and disability. Manual therapy and therapeutic exercises were applied to address the identified impairments. Manual therapy techniques included soft tissue mobilization, joint mobilization, and joint manipulation. The patient's cervical range of motion was improved and the disability score improved from 25% to 19.5% 3 days after the initial session addressing the thoracic spine. Following a second session also addressing thoracic spine impairments and the use of therapeutic exercises for 7 days, the disability score improved to 11.1%. At the final visit 17 days following the third visit, which focused on addressing the cervical spine impairments, there was complete resolution of signs and symptoms and disability. Interventions addressing the impairments of the upper thoracic and cervical spine region were associated with reducing pain, increasing cervical range of motion, and facilitating return to work and physical activities in a patient with a whiplash-associated disorder. There is a need for continued research investigating the efficacy of providing interventions to the thoracic spine for patients with whiplash-related injuries.

Common Tips for IMEs: Musculoskeletal Conversions: Musculoskeletal Conversions

Abstract Most impairments are expressed ultimately as a whole person impairment, and the musculoskeletal chapters of the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides) include instructions for converting regional impairments to whole person impairments using a percentage relationship. This article presents an extensive table that incorporates the conversion factors for extremity and spinal impairments. Occasionally evaluators need to convert spinal impairments from whole person to impairment of the spine, a process that is explained in the AMA Guides, Section 15.13. The conversion factors differ depending on whether the impairment was obtained using the Diagnosis-related estimate (DRE) method or the range-of-motion (ROM) method. For example, a 5% whole person impairment is an 8% upper extremity impairment, a 9% hand impairment, 23% thumb impairment, 46% index/middle finger impairment, or 93% ring/little finger impairment. The same 5% whole person impairment would convert to a cervical spine impairment of 14% cervical spine if the DRE method were used and 6% if the ROM method were used. For the lumbar spine, this would convert to 7% lumbar spine impairment if the DRE method were used and 6% if the ROM method were used. The table in this article provides values for converting foot to lower extremity impairment and for converting whole person impairment to regional spinal impairment.

Legal Update: Catastrophic Impairment: Catastrophic Impairment: Use of the AMA Guides in Ontario

Abstract Chapter 18, Pain, is the first attempt in the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Fifth Edition, to define comprehensive pain evaluation and rating. Chapter 18 focuses on situations in which the pain itself is a major cause of suffering, dysfunction, or medical intervention even though an examining physician can find no demonstrable active disease or autonomic changes. These statements likely would be rejected by rating systems that require a physiologic basis for rating. Other chapters in the AMA Guides typically account for pain as part of specific impairment ratings; for example, a physician who rates cervical spine impairment must decide if a rating for pain beyond the original rating is appropriate. Many rating systems would reject such a rating for pain because of its subjective nature, but, despite these difficulties, even restrictive rating systems may require the use of Chapter 18 because, according to the AMA Guides, no other available method exists for considering impairment of certain conditions such as postherpetic neuralgias or migraines. As the AMA Guides acknowledges, Chapter 18 seems to allow impairment ratings caused by pain and suffering but at the same time to forestall actually assigning a number. One hopes for refinements in our understanding of chronic pain treatment and outcomes; in the interim, knowledgeable raters should guide nonmedical personnel toward a reasonable understanding of this chapter.

Acquired Cervical Spine Impairment in Young Adults with Cerebral Palsy

Three patients with spastic cerebral palsy and no associated movement disorder--each of whom presented with loss of functional skills and delay in the definitive diagnosis of cervical myelopathy--are reported, in order to increase awareness of the possibility of cervical spine pathology in these adults. The possibility of myelopathy should be investigated when considering the etiology of functional deterioration. A functional neurological examination for all multiply disabled individuals is proposed as a reference for future comparison.