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Neck Pain
Version 2 Final
EBM – Neck Pain
Version 2 Final
MED S2 CMEP~0049(b)
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Document control
Version history
Version Date
Comments
2 Final
17 September 2010
Signed off by CMMS
2d draft
12 February 2010
External QA by Dr Thomas
2c draft
05 November 09
Int. Q.A.
2b draft
June 2009
Format and insert Appendix A
2a draft
March 2009
Review draft
2 draft
16th August 2006
Initial Draft
Changes since last version
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1. Introduction
Pain in the neck can be due to injury, a mechanical or muscular problem, a
trapped nerve caused by a bulge in one of the discs between the vertebrae, or
from arthritis of the neck.
Description
The stability of the neck depends mainly on the
musculature and ligamentous structures attached to the
cervical spine which consists of seven vertebrae which
articulate with each other through a system of joints of
unusual complexity. Each pair of cervical vertebrae is
separated by an intervertebral disc and a pair of
apophyseal joints but they also articulate through an
additional pair of apophyseal joints at their posterolateral
aspects.
The cervical spine provides a protective passageway for
the vertebral arteries and the spinal cord.
Most cervical problems are mechanical and mainly affect the joints and
associated ligaments and muscles
1. However, systemic disorders do give
rise to similar symptoms and need to be excluded by careful history and
examination techniques. There are also a number of important malignant
conditions which need to be excluded, including cervical spine
malignancy/metastasis and vertebral osteomyelitis, as well as head and
neck soft tissue tumours.
Neck pain is discussed in general followed by specific sections on
degenerative change, whiplash injury and torticollis.
Prevalence
The prevalence of neck related discomfort has been estimated as 9% for
adult males and 12% for adult females. It has been estimated that two
thirds of the population will suffer an episode of neck pain during their
lifetime
2,
3 and that up to one third of patients attending general practitioners
will complain of symptoms lasting more than six months or occurring in
bouts. Prevalence is highest in middle age, with women being affected
more than men. About 15% of hospital-based physiotherapy in the UK is for
neck pain
4.
Cervical dystonia (torticollis or “wry neck”) is the most common adult form of
focal dystonia, with prevalence in Europe of 5.7/100,000.
5
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2. Aetiology
Neck pain can arise from a variety of conditions including whiplash injury,
cervical dystonia and cervical spondylosis; although in the latter case there
is only poor correlation between symptoms and radiological evidence of
degenerative disease in the cervical spine
6.
Although mechanical neck pain is common in the adult population, has
significant morbidity and is a common cause of referral to hospital
specialists, there is a scarcity of studies on the natural history and outcome.
This may reflect the difficulty in assessing severity of neck pain, for while
symptoms are most prominent, signs, which are difficult to quantify, are
generally limited to tenderness and a reduced range of neck movement
7.
It is pain felt in the neck may be referred from many sources outwith the
musculoskeletal structures of the cervical spine. These may include the
mouth, jaw and teeth, the meninges, the middle and inner ear, the larynx,
pharynx and sinuses, the cervical lymph nodes and the shoulder girdle.
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3. Diagnosis
Symptoms arising in the neck are often poorly localised, making a precise
anatomical diagnosis difficult. However, particular features of the patient’s
history and examination can distinguish between common mechanical
disorders and more sinister disease.
As spondylosis is most common in the lower cervical spine, any pain is
usually felt low in the neck and often radiates to the occiput, trapezius and
inter-scapular areas. This distribution may be due to dural irritation. Painful
shoulder movement can lead to an erroneous diagnosis of a shoulder
problem. However, referred pain is rarely affected by shoulder movement
and pain varying on neck movement is normally related to the cervical spine.
Symptoms and signs of neck pain may be conveniently divided into those
arising from either articular, dural or nerve root problems.
Symptoms Signs
Articular
Intermittent neck pain movement
Asymmetrical restriction of neck
In occiput, vertex, trapezius,
Rarely pain on shoulder
Dural Pain
deltoid and inter-scapular regions adduction/external rotation
Weakness of triceps, fingers and
Severe pain in upper arm,
Nerve root
wrist
dorsum of forearm, dorsum
Usually C7
Absent triceps reflex and sensory
extensors
impairment
The presence of bilateral symptoms or signs or involvement of more than
one nerve root usually signifies more severe or possibly sinister pathology,
e.g. cold compression due to tumours.
Plain x-rays of the cervical spine are rarely helpful in diagnosing the cause
of neck pain except to look for major injury after trauma, an observation
confirmed by a study in elderly patients which concluded that there was no
place for routine radiological examination of the cervical spine in patients
with vertebrobasilar insufficiency.
Radiologically degenerative changes occur commonly in people over the
age of forty, are often symptomless and do not correlate well with clinical
findings.
Magnetic Resonance Imaging (MRI) can be used to diagnose and assess
anatomical problems such as atlantoaxial subluxation in rheumatoid
disease, tumours, infections (abscesses) and injury.
It can identify prolapsed cervical discs but is not yet able to demonstrate the
anatomical abnormalities attributable to neck pain in most cases.
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Differential Diagnosis
Infective
Infection in the cervical spine or retropharyngeal space causes persistent
pain with symmetrically restricted movement. Although the patient is usually
unwell, this is not a constant feature. The ESR, plasma viscosity and CRP
is raised early but bone and joint changes on x-ray are a late feature.
Expansion of the retropharyngeal space as a soft tissue shadow may be
seen on a lateral x-ray of the neck.
Non-infective inflammation
This occurs in a wide range of connective tissue disorders particularly:
Rheumatoid arthritis
The upper cervical synovial tissue is affected causing ligamentous
weakness and joint instability. Atlantoaxial subluxation is common in about
25% of inpatients with rheumatoid arthritis, while destruction of the lateral
processes of the atlas can lead to vertical subluxation.
Ankylosing spondylitis This classically presents with sacroiliac problems but neck stiffness can be a
presenting feature.
Polymyalgia rheumatica
Polymyalgia rheumatica and giant cell arthritis can also present with neck
pain. Classically they occur in the elderly, with pain and stiffness which is
symmetrical. The classical presentation involving shoulders etc is usually a
straightforward diagnosis, but occipital artery involvement causing neck pain
and stiffness is more difficult.
Neoplastic disease This is suggested by unremitting pain which radiates to both arms and is
worse at rest. Sleep disturbance is common and neck movements are
usually painfully limited in all directions.
The following diseases should be considered in the differential diagnosis of
cervical spondylosis with myelopathy: motor neurone disease, multiple
sclerosis, spinal cord tumour and syringomyelia.
While with cervical spondylosis with radiculopathy: nerve entrapment
syndromes (carpal tunnel etc.) and brachial neuritis should be excluded.
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4. Degenerative Change
Mild to moderate degenerative changes are often asymptomatic
8, but when
degenerative changes are severe they may be associated with neck pain
which, because it is mechanical in nature, is usually intermittent and related
to use. With normal ageing the intervertebral discs fragment, lose water
content and collapse. This causes increased mechanical stress at the
cartilaginous end plates and osteophyte formation which can extend
ventrally and in some cases encroach on nervous tissue.
Osteophyte formation, most common in patients over the age of 55 years,
should be differentiated from the soft disc herniations which occur in the
young and middle aged. The most severe form of cervical spondylosis can
involve the nerve roots (radiculopathy), the vertebrobasilar circulation and
the spinal cord itself (myelopathy). Cervical spondylosis is a condition in
which degenerative changes in both the intervertebral disc and the annulus,
as well as the formation of bony osteophytes, narrows the cervical canal or
neural foramina which can, in severe cases, lead to cord compression.
Spondylosis is most common in the low cervical spine, between C5-C6 and
C6-C7, the joints associated with flexion and extension, and much less
commonly in the upper spine, C1-C2 and C3-C4, which are associated with
rotatory movements. About 60-85% of middle-aged adults are affected by
spondylotic changes between the third and seventh vertebrae.
Intervertebral discs from C2-3 and below are subject to significant
deformation during flexion and extension. Disc herniation can lead to
compression of the nerve root (radiculopathy) or of the spinal cord
(myelopathy). Eight pairs of spinal nerves exit bilaterally through the
intervertebral foramina and each is named from the vertebra below.
Therefore a herniated disc at the C5-6 level will most commonly involve the
C6 nerve and its area of distribution.
Cervical spondylotic myopathy has a variable natural course. It usually
develops insidiously although episodes of abrupt deterioration do occur. It
was assumed at one time that the spondylitic changes in the cervical spine,
which occur with increasing age, may impinge on the spinal canal causing
chronic cord compression. However, at operation, the degree of cord
compression was often not consistent with the neurological disturbance and
decompression seldom led to significant neurological improvement. It
seems therefore that production of the myopathy in these cases is more
than just simple compression and may involve compression of the radicular
and/or anterior spinal arteries
9.
Fortunately, most adults with cervical spondylosis — nearly 90 percent —
will not lose nerve function, even temporarily.
10
High compressive myelopathy (C3-C5) causes numb clumsy hands and is
associated with loss of manual dexterity, diffuse non-specific weakness of
the arms and abnormal sensations. Lesions affecting levels C5-C8 cause a
syndrome of spasticity and proprioceptive loss in the legs. Improvement has
been quoted to occur in 30-50% of patients with non-operative treatment.
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The various myelopathic syndromes, e.g. Brown-Séquard, have different
localising symptoms depending on the position of the compression.
Acute cord compression by disc protrusion and spinal cord damage caused
by a combination of cervical spondylosis and hyperextension injury
(whiplash) may lead to severe cord compression, but is not related to
spondylotic myelopathy.
Treatment
Episodes of acute neck pain are generally self limiting and require only
symptomatic treatment.
Active treatment involving mobilisation (moving the joints within their
restrictive range) and manipulation (moving the joints briefly beyond their
restrictive range) is now the treatment of choice.
Collars, if prescribed, are generally only worn for activities likely to
exacerbate the pain and then for only two to three weeks.
Advice on the correction of postural abnormalities and neck stretching
exercises is beneficial.
Radicular pain is treated with rest and wearing a collar for up to two weeks.
Approximately 75% of patients have complete or partial but significant relief of
symptoms with non-operative management.
11 Features suggesting a poor response
to nonoperative treatment include advanced age, duration of symptoms, severity of
myelopathy, and severity of stenosis
12
Limited studies have shown some improvement with muscle relaxants
(cyclobenzaprine)
13 but 60% of patients demonstrate side effects, mainly dry mouth
and sedation.
14
A controlled trial comparing acupuncture with placebo failed to show a significant
difference in pain relief but there were concerns about the quality of the placebo.
15 Intractable nerve root symptoms and the rare occurrence of spinal cord
compression are investigated further and can require surgical intervention if
conservative measures fail.
Despite early recognition and improved surgical techniques, not all authors
agree that surgery improves the variable clinical spectrum of cervical
spondylotic myelopathy. A variety of surgical techniques have been
proposed including cervical laminectomy and anterior spinal fusion but the
results are often disappointing and no single procedure has been found to
be superior over another
16. In a recent series
17 anterior cervical discectomy
and fusion was associated with an acceleration of degenerative changes at
the fused and adjacent levels.
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Prognosis
Neck pain from degenerative cervical disease usually responds to simple
measures such are mobilisation and analgesia.
Spondylotic radiculopathy also resolves with conservative therapy in most
cases and surgical intervention is not considered unless there is persistent
pain or progressive neurological problems.
Myelopathy is the most severe form of the disease but a third to a half of
these patients improve with simple measures such as wearing a collar
18.
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5. Whiplash injury
Between 2002 and 2009 the incidence of whiplash injury increased by 25%
in the UK, and constitute 76% of motor insurance claims. It is estimated that
they cost the UK economy £3.63billion a year. Whiplash injury, an acute soft
tissue injury (extension sprain
19) in the neck after a road traffic accident or
sporting accident may occur after front, side or rear collision. In road traffic
accidents proper adjustment of head restraints should prevent whiplash
injury in rear collisions but there is a general lack of knowledge on proper
positioning of the head restraint.
(Image from
www.bodymovesphysio.com.au )
Although the mechanism of injury appears well understood as a
hyperextension strain beyond the normal anatomical limit, the immediate
pathology and resultant long-term effects are not known and therefore
treatment is empirical.
It has been suggested that whether or not a victim pursues litigation is
related to the severity of injury
20. However a study of 100 patients, mean
age 47 years, who had sustained neck ‘sprains’ as a result of rear impact
does not confirm this impression. In nearly 60% of these cases, the patients
were free of significant pain before settlement of their claims.
Factors in the prognosis in whiplash injury were reported upon as follows:
The patient’s sex was not statistically related to the duration or grade of
pain.
Age over 45 years was associated with longer duration of pain.
Onset of pain occurring at least twelve hours after the accident was
associated with a quicker recovery and a better end result.
Previous symptoms in the cervical spine before injury resulted in a
longer period of pain.
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Cervical spondylosis diagnosed by X-ray at or prior to the injury was
associated with longer duration of symptoms.
The presence of root pain at any time after injury bore no relation to
either the duration of symptoms or the final outcome.
Grading whiplash injury
The Quebec Task Force developed a classification for grading whiplash
injury
21.
Parameters:
(1) Neck complaint (pain, stiffness, tenderness)
(2) Musculoskeletal signs (decreased range of motion and/or point
tenderness)
(3) Neurological signs (decreased or absent deep tendon reflexes [DTR],
weakness, sensory deficit)
(4) Vertebral fracture or dislocation
Neck
Musculo-
Neurological
Fracture or
Grade
Complaint
skeletal
Signs
Dislocation
absent absent absent absent 0
present absent absent absent 1
present present absent absent 2
present NA present
absent 3
NA NA NA
present
4
The following findings may be seen with any grade and are not used for
classification: headache, dizziness, deafness, memory loss, dysphagia and
temporomandibular joint pain.
Treatment
Caution is needed when attempting to draw conclusions regarding the
efficacy of conservative treatments in whiplash-patients, because of the
paucity of high-quality studies.
‘It appears that "Rest makes rusty." In other words, rest and immobilization
using collars are not recommended for the treatment of whiplash, while
active interventions, such as advice to 'maintain usual activities' might be
effective in whiplash-patients’
22. Physiotherapy may be of benefit, as well as
Maitland’s manipulations. Non-steroidal anti-inflammatory analgesia can be
used. In the chronic cases, facet blocks have been shown to show some
short-term benefit, but have a 50% recurrence rate within a week. Botulinum
toxin has been used and shown to produce only a 7% reduction in pain. In
brachalgia, cervical fusion has produced a 32% success rate19.
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Prognosis
In the UK up to 40% of people continue to report symptoms 15 years after
the accident.
23 Just under 50% make a permanent recovery and 4.3% are
permanently disabled.
24 There is compelling data from Germany and Greece indicating that the
outcome of whiplash injury is culturally dependent.
25
In a prospective study of 210 consecutive persons experiencing rear-end
collisions in Kaunas, Lithuania 47% reported initial symptoms but one year
after the accident they had no more symptoms than a group of 210 matched
controls who had not been in accidents
26. They concluded that, where there
was no preconceived notion of chronic pain following rear-end collisions; no
fear of long-term disability and usually no involvement by therapists,
insurance companies or lawyers, symptoms from `whiplash injury' were brief
and self- limiting.
The wide variations in whiplash injury incidence and/or chronicity reported
from country to country are more plausibly explained by cultural and
psychosocial factors than by purely mechanical ones. The signs and
symptoms of whiplash syndrome include psychological as well as physical
components. This may involve impaired concentration, poor memory,
somatoform disorder, post-traumatic stress disorder and depression. These
symptoms may be as severe as after trauma involving multiple fractures. A
pre-accident psychological history may predispose to these
manifestations.19
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6. Torticollis (Cervical Dystonia) 27, 28
Spasmodic torticollis, also known as cervical dystonia, and commonly called
“wry neck”, is the condition of spasm affecting the muscles of the neck,
causing the head to assume unnatural postures.
The head may be pulled backwards (retrocollis), forwards (anterocollis) or to
the side (torticollis), depending on which muscle groups are affected. This
muscle spasm may occur intermittently or continuously. The cause of
cervical dystonia is not known.
In children, it is sometimes associated with congenital abnormalities of the
shape of the head or of the spine, but it may occur at any age. Cervical
dystonia may persist for several years, or sometimes for life. Some patients
recover spontaneously.
The movements may be sustained or jerky (myoclonic torticollis). Muscle
spasms or pinching nerves in the neck can be very painful. The neck may
eventually be held permanently in one position.
Torticollis usually develops gradually. At first, the patient may notice that the
head turns during everyday activities. In about a quarter of patients the
hand may also develop some tremor, especially if trying to correct the
involuntary movement. The tremor is common but not usually disabling and
is referred to as an enhanced physiologic tremor.
The severity of torticollis can vary and may be worse if the patient is under
stress. Occasionally drinking alcohol can improve the torticollis.
Some sufferers have a history of head or neck injury, but as yet there is no
evidence to support the theory that torticollis is directly related to trauma.
Patients with torticollis often find that their daily lives are affected. Head
turning can prevent a proper view of the road when driving.
It may become difficult to eat, brush teeth or apply makeup.
Many sufferers find embarrassment and anxiety the major handicap.If
chronic, torticollis can lead to cervical spondylosis, radiculopathy and
myelopathy
29.
Prevalence
5.7 per 100,000 in Europe.
There are thought to be 10,000 people in the UK suffering from this
condition. The average age of onset is in the early 40s and more women
are affected than men.
Aetiology
Spasmodic (or adult-onset) torticollis is usually idiopathic. About 5% of
patients with spasmodic torticollis have a family history. One third of these
patients have other dystonias (e.g. eyelids, face, jaw, hand). Torticollis can
also be congenital or secondary to other conditions such as lesions of the
brain stem and basal ganglia
30.
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Diagnosis
The diagnosis is based on characteristic symptoms and signs and exclusion
of alternative diagnoses, such as the following:
Tardive dyskinesia can cause torticollis but can usually be distinguished by
a history of chronic antipsychotic use and involuntary movements in muscles
outside of the neck.
Basal ganglia disease and occasionally CNS infections can cause
movement disorders but usually also involve other muscles.
Also, CNS infections are usually acute and cause other symptoms.
Neck infections or tumours are usually differentiated by features of the
primary process.
Antipsychotics and other drugs can cause acute torticollis, but the
symptoms usually develop in hours and resolve within days.
Torticollis may be graded by the Toronto Western Spasmodic Torticollis
Rating Scale
31
Treatment30
Spasms can sometimes be temporarily inhibited by physical therapy and
massage, including sensory biofeedback techniques (slight tactile pressure
to the jaw on the same side as head rotation
- sensory trick) and any light
touch.
Touching an affected or adjacent body part can sometimes significantly
reduce contractions. For example, placing a hand on the chin, side of the
face or back of the head may reduce neck muscle contractions.
People with dystonia typically discover and use this trick to reduce their own
dystonic contractions. Some physical therapists have developed head or
neck braces, hand splints or other devices that mimic the sensory trick.
Injections of botulinum toxin type A & B into the dystonic muscles can
reduce painful spasms for 1 to 3 months in about 70% of patients, restoring
a more neutral position of the head. However, this treatment can lose
effectiveness with repeated injections because antibodies develop against
the toxin.
Drugs can usually relieve pain. However they suppress dystonic movements
in only about 25 to 33% of patients. Anticholinergics such as trihexyphenidyl
may help. All drugs should be started in low doses. Doses should be
increased until symptoms are controlled or intolerable adverse effects
(particularly likely in the elderly) develop.
Surgery is controversial in adult torticollis. The most successful surgical
approach, selective peripheral denervation, selectively severs nerves to
affected neck muscles, permanently weakening or paralysing them. Results
are favourable when the procedure is done at centres with extensive
experience. Patient selection for this procedure is important. Patients
should be offered the procedure only when their disease has become
refractory to best non-surgical treatment.
27 In congenital torticollis
sternomastoid release is a more successful and accepted procedure.
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Rarely, an emotional problem contributes to spasmodic torticollis when
psychiatric treatment is indicated.
Prognosis is best if symptom onset coincided with exogenous stress.
Prognosis
Most patients find the condition deteriorates over the first five years, but
their symptoms then stabilise. One third of patients progress to a
segmental dystonia, usually involving the arm. The symptoms of about
10 per cent may resolve spontaneously, but then later recur.
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7. Main Disabling Effects of Neck Pain
These can be considered under musculoskeletal, neurological and
ischaemic factors. Ultimately, significant disability arising from pathology in
the neck may lead to chronic periodic pain, bent jerky gait and clumsy
hands.
Musculoskeletal disorders give rise to stiffness and acute or developing
chronic pain. In many cases of acute pain they settle without medical
advice. Treatment for acute pain includes, rest, support, education about
movement and analgesia. About 10% of those presenting for medical
opinion progress to chronic pain. This is both local and referred to head,
shoulder or arm.
A ‘functional disability scale’ has been developed [Appendix A – The
Copenhagen Neck Functional Disability Scale] and used to demonstrate that
patients with ‘chronic pain’ have reduced neck muscle strength and
endurance, particularly of the extensor muscles.
32
Lesions at C1-2 refer pain to the occiput and at C5-6 refer pain to the
forearm and hand.
Neurological disabilities due to disc herniation or isolated osteophytes may
be localised, of a lower motor neurone type1 and related to one or more
nerve roots.
In spondylosis, multiple level disease develops in 60-85% of cases.
The C6 and C7 nerve roots are most commonly affected causing weakness
of the triceps muscle which may affect reaching but not lifting, and sensory
impairment of the index and middle fingers which may affect pinch grip
function.
75% of patients with radiculopathy as a result of cervical spondylosis will
resolve spontaneously
18.
Involvement of a nerve root will involve loss of power with flaccid paralysis
and referred pain and paraesthesia.
Myelopathy produces more general effects and is the result of cord
compression. This may be more likely in people with narrow vertebral
foramina which is usually a familial complaint and is also associated with
achondroplasia. Mechanical relief of cord compression does not always
lead to improvement because ischaemia of the cord is also though to be a
factor.
Myelopathy with cord compression at C3-5 causes clumsiness of the hands
with weakness and loss of dexterity.
Compression lower down at C5-8 causes spasticity with loss of
proprioception in the legs.
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Myelopathy is a serious condition and although the progress of the disease
varies greatly, 30-50% can improve
with non-surgical treatment1.
Extreme cases will exhibit urinary frequency and urgency.
Major anatomical deformity in the cervical spine produces cerebellar
ischaemia resulting in giddiness especially on rotation or extension of the
neck.
The Division of Industrial Accidents at the University of California has
attempted to develop guidelines for the evaluation of medical factors of
disability in neck (and back) injuries over the past ten years
33.
The guidelines are very comprehensive and consist of a list of 37 factors of
disability.
The first ten factors are ‘subjective’ and in this system only count towards a
final assessment if supported by ‘objective’ factors such as muscle strength.
Trigger points and ranges of flexion, extension etc.
Currently many of the objective factors require measurement using
instruments which have significant inter-observer error.
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Degenerative changes following anterior discectomy. Acta Radiologica 1996;
37: 614-617.
18 McCormack B M, Weinstein P R Cervical Spondylosis. An update. 1996; 165(1/2): 43-51
19 Parmar H V, Raymakers R. Neck injuries from rear impact road traffic accidents: prognosis
in persons seeking compensation. Injury. 1993; 24(2): 75-78
20 Pennie B, Agambar I. Patterns of injury and recovery in whiplash. Injury. 1991; 22: 57
21 Spitzer WO, Skovron ML, et al. Scientific monograph of The Quebec Task Force on
Whiplash-Associated Disorders: Redefining "whiplash" and its management. Spine. 1995; 20
(Supplement): 8S to 58S.
22 Conservative treatment for whiplash. Cochrane Database Syst Rev. 2001; (4):CD003338
Verhagen AP, Peeters GG, de Bie RA, Oostendorp RA. Department of General Practice,
Erasmus University Rotterdam, P.O. Box 1738, 3000 DR Rotterdam, Netherlands.
23 www.clinicalevidence.bmj.com
24 Bannister G, Amirfeyz R, Kelley S, Gargan M. Whiplash injury. Journal of Bone and Joint
Surgery. (British volume): Jul 2009. Vol. 91B(7);845-51
25 Kwan O, Friel J. Clinical relevance of the sick role and secondary gain in the treatment of
disability syndromes.
Med Hypo 2002;
59: 129-34.
26 Obelieniene D, Schrader H, Bovim G, Miseviciene I, Sand T. Pain after whiplash: a
prospective controlled inception cohort study. • Neurol Neurosurg Psychiatry 1999;66:279±83
27 National Institute Clinical Excellence Interventional Procedure Guidance 80. Selective
peripheral denervation for cervical Dystonia. August 2004.
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28 Dr Helen Hanson, Movement Disorders Unit, King's College Hospital, London and Dr K
Ray Chaudhuri, Movement Disorders Unit, King's College Hospital, London.
www.netdoctor.co.uk
29 Hagenah JM, Vieregge A, Vieregge P (2001) Radiculopathy and myelopathy
in patients with primary cervical dystonia. Eur Neurol 45: 236–240
30 Sally Pullman-Mooar, MD. The Merck Manuals Online Library. June 2008
31 Consky ES. Clinical assessments of patients with cervical dystonia. In: Jankovic J, Hallett
M, eds. Therapy With Botulinum Toxin. New York, NY: Marcel Dekker; 1994:211-237
32 Jordan Alan (Chiropractor) Functional assessment of the cervical spine and treatment of
chronic neck pain patients. Danish Medical Bulletin 1997; 44(3): 325-6
33 Clark W, Haldeman S
The development of guidelines for the evaluation of disability in neck
and back injuries. Spine; 18(13): 1736-1745
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APPENDIX A
The Copenhagen Neck Functional Disability Scale
Overview: The Copenhagen Neck Functional Disability Scale can be used to evaluate the
disability experienced by patients with neck pain. The scores can be monitored over time to
evaluate the disease course and response to any interventions.
Questions:
(1) Can you sleep at night without neck pain interfering?
(2) Can you manage daily activities without neck pain reducing activity levels?
(3) Can you manage daily activities without help from others?
(4) Can you manage putting on your clothes in the morning without taking more time
than usual?
(5) Can you bend over the washing basin in order to brush your teeth without getting
neck pain?
(6) Do you spend more time than usual at home because of neck pain?
(7) Are you prevented from lifting objects weighing from 2-4 kilograms due to neck
pain?
(8) Have you reduced your reading activity due to neck pain?
(9) Have you been bothered by headaches during the time that you have had neck
pain?
(10) Do you feel your ability to concentrate is reduced due to neck pain?
(11) Are you prevented from participating in your usual leisure time activities due to
neck pain?
(12) Do you remain in bed longer than usual due to neck pain?
(13) Do you feel that neck pain has influenced your emotional relationship with your
nearest family?
(14) Have you had to give up social contact with other people during the past two
weeks due to neck pain?
(15) Do you feel that neck pain will influence your future?
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Direction of questions:
• "positive" (a yes indicates good function): 1-5
• "negative" (a yes indicates poor function): 6 - 15
Response
Points for "Positive"
Points for "Negative"
Directed
Directed
yes
0
2
occasionally
1
1
no
2
0
disability index = SUM(points for all 15 questions)
Interpretation:
• minimum score: 0
• maximum score: 30
• The higher the score the greater the disability.
References:
Jordan A Manniche C et al. The Copenhagen Functional Disability Scale: A study of reliability
and validity. J Manipulative Physiological Therapeutics. 1998; 21: 520-527.
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APPENDIX B
Toronto Western Spasmodic Torticollis Rating Scale
I. Torticollis Severity Scale (maximum=35; sum of A through F)
A. Maximal Excursion: Rate the maximum amplitude of excursion by asking the patient not to oppose
the abnormal movement; the examiner may use distracting or aggravating maneuvers. When the degree
of deviation is between scores, choose the higher of the two.
1. Rotation (turn: right or left)
0=None (0°)
1=Slight (<1/4 range, 1°-22°)
2=Mild (1/4-1/2 range, 23°-45°)
3=Moderate (1/2-3/4 range, 46°-67°)
4=Severe (>3/4 range, 68°-90°)
2. Laterocollis (tilt: right or left, exclude shoulder elevation)
0=None (0°)
1=Mild (1°-15°)
2=Moderate (16°-35°)
3=Severe (>35°)
3. Anterocollis/Retrocollis (a or b)
a. Anterocollis
0=None
1=Mild downward deviation of chin
2=Moderate downward deviation (approximates 1/2 possible range)
3=Severe (chin approximates chest)
b. Retrocollis
0=None
1=Mild backward deviation of vertex with upward deviation of chin
2=Moderate backward deviation (approximates 1/2 possible range)
3=Severe (approximates full range)
4. Lateral Shift (right or left)
0=Absent
1=Present
5. Sagittal Shift (forward or backward)
0=Absent
1=Present
B. Duration Factor: Provide an overall score estimated through the course of the standardized
examination after estimating the maximal excursion (exclusive of asking the patient to allow the head to
deviate maximally) (weighted × 2).
0=None
1=Occasional deviation (<25% of the time, most often submaximal)
2=Occasional deviation (<25% of the time, often maximal) or intermittent deviation (25%-50% of the
time, most often submaximal)
3=Intermittent deviation (25%-50% of the time, often maximal) or frequent deviation (50%-75% of the
time, most often submaximal)
4=Frequent deviation (50%-75% of the time, often maximal) or constant deviation (~75% of the time,
most often submaximal)
5=Constant deviation (>75% of the time, often maximal)
C. Effect of Sensory Tricks
0=Complete or partial relief by one or more tricks
1=Partial or only limited relief by tricks
2=Little or no benefit from tricks
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D. Shoulder Elevation/Anterior Displacement
0=Absent
1=Mild (<1/3 possible range) and intermittent or constant
2=Moderate (1/3-2/3 possible range) and constant (>75% of the time) or severe (>2/3 possible range)
and intermittent
3=Severe and constant
E. Range of Motion (without the aid of sensory tricks). If limitation occurs in more than one plane of
motion, use the individual score that is highest.
0=Able to move to extreme opposite position
1=Able to move head well past midline but not to extreme opposite position
2=Able to move head barely past midline
3=Able to move head toward but not past midline
4=Barely able to move head beyond abnormal posture
F. Time (up to 60 seconds) for which patient is able to maintain head within 10° of neutral position
without using sensory tricks (the mean of two attempts).
0=>60 seconds
1=46-60 seconds
2=31-45 seconds
3=16-30 seconds
4=<15 seconds
II. Disability Scale (maximum=30; sum of A through F)
A. Work (occupation or housework/home management)
0=No difficulty
1=Normal work expectations with satisfactory performance at usual level of occupation but some
interference by torticollis
2=Most activities unlimited, selected activities very difficult and hampered but still possible with
satisfactory performance
3=Working at lower than usual occupation level; most activities hampered, all possible but with less
than satisfactory performance in some activities
4=Unable to engage in voluntary or gainful employment; still able to perform some domestic
responsibilities satisfactorily
5=Marginal or no ability to perform domestic responsibilities
B. Activities of Daily Living (eg, feeding, dressing, or hygiene, including washing, shaving, makeup, etc)
0=No difficulty with any activity
1=Activities unlimited but some interference by torticollis
2=Most activities unlimited, selected activities very difficult and hampered but still possible using
simple tricks
3=Most activities hampered or laborious but still possible; may use extreme "tricks"
4=All activities impaired, some impossible or require assistance
5=Dependent on others in most self-care tasks
C. Driving
0=No difficulty (or has never driven a car)
1=Unlimited ability to drive but bothered by torticollis
2=Unlimited ability to drive but requires "tricks" (including touching or holding face, holding head
against headrest) to control torticollis
3=Can drive only short distances
4=Usually cannot drive because of torticollis
5=Unable to drive and cannot ride in a car for long stretches as a passenger because of torticollis
D. Reading
0=No difficulty
1=Unlimited ability to read in normal seated position but bothered by torticollis
2=Unlimited ability to read in normal seated position but requires use of "tricks" to control torticollis
3=Unlimited ability to read but requires extensive measures to control torticollis or is able to read only
in nonseated position (eg, lying down)
4=Limited ability to read because of torticollis despite tricks
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5=Unable to read more than a few sentences because of torticollis
E. Television
0=No difficulty
1=Unlimited ability to watch television in normal seated position but bothered by torticol is
2=Unlimited ability to watch television in normal seated position but requires use of tricks to control
torticollis
3=Unlimited ability to watch television but requires extensive measures to control torticollis or is able
to view only in nonseated position (eg, lying down)
4=Limited ability to watch television because of torticollis
5=Unable to watch television more than a few minutes because of torticollis
F. Activities Outside the Home (eg, shopping, walking about, movies, dining, and other recreational
activities)
0=No difficulty
1=Unlimited activities but bothered by torticollis
2=Unlimited activities but requires simple "tricks" to accomplish
3=Accomplishes activities only when accompanied by others because of torticollis
4=Limited activities outside the home, certain activities impossible or given up because of torticollis
5=Rarely if ever engages in activities outside the home
III. Pain Scale (maximum=20; sum of A through C)
A. Severity of Pain: Rate the severity of neck pain due to torticollis during the last week on a scale of 0-
10, where a score of 0 represents no pain and 10 represents the most excruciating pain imaginable.
Score calculated as [worst+best+(2×usual)]/4.
Best_____
Worst_____
Usual_____
B. Duration of Pain
0=None
1=Present <10% of the time
2=Present 10%-25% of the time
3=Present 26%-50% of the time
4=Present 51%-75% of the time
5=Present >75% of the time
C. Disability Due to Pain
0=No limitation or interference from pain
1=Pain is quite bothersome but not a source of disability
2=Pain definitely interferes with some tasks but is not a major contributor to disability
3=Pain accounts for some (less than half) but not all of the disability
4=Pain is a major source of difficulty with activities; separate from this, head pulling is also a source
of some (less than half) disability
5=Pain is the major source of disability; without it, most impaired activities could be performed quite
satisfactorily despite head pulling
Reference: Consky ES. Clinical assessments of patients with cervical dystonia. In:
Jankovic J, Hallett M, eds. Therapy With Botulinum Toxin. New York, NY: Marcel
Dekker; 1994:211-237
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