TMD and Neck Pain

The relationship between temporomandibular joint dysfunction (TMD) and whiplash is an area of strong debate in medical and engineering circles. Clinically, a great number of patients suffering from whiplash injuries report TMD problems; biomechanically, engineers have been unable to show what happens during a rear end collision that causes injury to the temporomandibular joint.

Part of the problem may very well be that TMD pain may simply be an integral part of neck pain, rather than a separate, unrelated lesion caused by the collision itself. This theory is given credence by a new study that looked specifically at the interrelationship between neck pain and TMD symptoms in the general population.

The goal of this study was to find associations between TMD and neck pain. The researchers used a standard questionnaire that focused on symptomatology of both neck pain and TMD. The authors evaluated TMD by the patient’s experience of any joint sounds (such as clicking), stiffness or fatigue in jaws, difficulty with opening mouth wide or it locking in, and any facial or jaw pain. Neck pain was defined as, “a troublesome pain experienced within the last year in the neck area between the occipital bone and the spinous process of the seventh cervical vertebra.” 438 subjects completed the questionnaire.

188 patients (38.9%) had “troublesome” neck pain. The authors noted that this rate increased with age, and affected females more than males. A history of trauma did not correlate to troublesome neck pain. 266 subjects (55.1%) were identified with TMD pain.

When the results of the study were analyzed statistically, the authors found that there is indeed a significant association between neck pain and TMD pain. In particular, the strongest relationship exists between neck pain and facial and jaw pain.

The authors also suggest some anatomical reasons why the two conditions are so closely linked:

  • The authors refer to experimental studies that show that some neurologic circuits converge in the trigeminal nerve, showing that jaw functioning is inextricably linked with the cervical spine.
  • Biomechanically, “the masticatory muscles enter into a synergic or antagonistic relationship with cervical muscles acting as extensors or flexors of the cervical spine. Variations of length and of tonic response in cervical muscles might influence the activity of masticatory muscles.”

The authors conclude that future research should investigate not only the role of direct trauma on the TMJ, but also the general “topography of pain and related structures” of the head, face, and spine.

Ciancaglini R, Testa M, Radaelli G. Association of neck pain with symptoms of temporomandibular dysfunction in the general adult population. Scandinavian Journal of Rehabilitation Medicine 1999;31:17-22.

Analgesic-Rebound Headache: Overdiagnosed?

In a recent editorial, Dr Robert S. Kunkel raises serious questions about analgesic-rebound headache, and meets the issues with skeptical pragmatism:

“I certainly agree that analgesic-rebound headache due to combination-type analgesics and ergotamine tartate is a very significant problem that I see daily in my headache clinic. However, I am not convinced that the frequent use of small amounts of pain aspirin, acetaminophen, or an NSAID is very often a significant factor in the etiology of transforming an episodic headache into a chronic daily headache…”

“I feel we are mislabeling a lot of patients with chronic headache as analgesic-rebound headache simply because they take aspirin or ibuprofen once or twice a day. Hopefully, this condition will be better defined in the future as we learn more about the cause of pain in the head.”

Kunkel RS. Analgesic-rebound headache: headache of the nineties. Headache Quarterly 1998;9:231-232.

The Relationship Between Cervical Radiographic Findings and Pain

What is the relationship between radiographic findings and neck pain and disability? This study took the cervical radiographic findings from 675 patients, and compared this information to self-reported pain and disability ratings to try to find an answer to this question.

The researchers examined the cervical spine radiographs, and recorded all evidence of degenerative findings; the study reported that most degeneration was found at C5, C6, and C4—in order of decreasing frequency. Interestingly, the authors found that spinal degeneration was not related to a history of neck trauma—although patients with a history of trauma reported more pain and disability than non-trauma patients.

The study also reported that those patients with spinal degeneration were more likely to experience chronic neck pain.

Marchiori DM, Henderson CNR. A cross-sectional study correlating cervical radiographic degenerative findings to pain and disability. Spine 1996;21(23):2747-2752.

Smoking linked to back pain

New research suggests that smoking can increase your risk of back pain.

In a study of 95,000 nurses, women who smoked were three times more likely to develop arthritis. This inflammatory arthritis causes pain in  the low back and sacrum. Past smokers were 1 and a half times more likely to develop arthritis, and women who smoked for over 25 years had the highest risk of all. Researchers suggested that smokers may be more susceptible to arthritis because smoking could induce oxidative stress that causes inflammation and harms the immune system.

In another new study, smokers were more likely to have an early onset of inflammatory back pain. Compared to non-smokers, patients who smoked had greater disease activity, worse function, and a poorer quality of life. MRI scans revealed that smokers were also more likely to have structural lesions on their spines and sacroiliac joints. More severe symptoms forced smokers to miss work more often than nonsmokers. Researchers recommended that patients with inflammatory back pain be “strongly advised” to quite smoking.

If  you suffer from back pain, your chiropractor can ease your pain while supporting you in making healthy lifestyle choices to reduce pain and improve your overall health. Call our office to learn more.


Chung HY, Machado P, Heijde D, et al. Smokers in early axial spondyloarthritis have earlier disease onset, more disease activity, inflammation and damage, and poorer function and health-related quality of life: results from the DESIR cohort.Annals of the Rheumatic Diseases 2012;71:809-816. doi:10.1136/annrheumdis-2011-200180.

Li W, Han J, Qureshi A. Smoking and risk of incident psoriatic arthritis in US women. Annals of the Rheumatic Diseases 2012;71:804-808. doi 10.1136/annrheumdis-2011-200416.

Walsh, Nancy. Smoking Tied to Back Pain, Arthritis. Medpage Today. May 18,2012. Accessed May 24, 2012. //

Rheumatoid Arthritis Articles


Emotional Disclosure in Rheumatoid Arthritis Patients

Numerous studies have documented that psychological issues play a role in pain conditions, although the exact nature of this relationship is not well understood.

In this study, researchers took a group of 36 rheumatoid arthritis (RA) patients, and had them talk privately into a tape recorder about a stressful event in their lives (the Disclosure group). Another 36 RA patients were asked to talk about trivial topics (the Control group). Both groups participated in these activities for four consecutive days, and the researchers measured pain levels and psychological functioning. The RA patients were also evaluated at two weeks and at four months after the experiment.

The Disclosure patients were found to have significantly increased negative mood reactions immediately after the disclosure period—especially on scales of Dejection/Depression, Anger/Hostility, and Fatigue/Inertia. No such trend was found in the Control patients.

The authors found that disclosure did not have an effect on pain. However,Disclosure patients did show significantly reduced emotional dysfunction and increased general health over a period of four months, as compared to the Control group patients.

The authors explain the role of emotions and physical health as such:

“The effects of a stressful experience appear to be mediated by one’s emotional processing of the event. Although the normal response to a stressful event is a complex process that may involve both avoidance and intrusion of memories, most theorists agree that excessive avoidance, or prolonged and rigid inhibition of negative memories, prevents the reappraisal, reintegration, and eventual resolution of the experience…Because inhibition requires effort, chronic psychological arousal may occur, potentially leading to physical symptoms, autonomic and immune dysfunction, and disease. In contrast, volitional and repeated exposure to distressing memories permits their emotional processing and resolution, potentially yielding better subjective, behavioral, and physical health.”

The authors conclude by stating that addressing traumatic life events, as well as how the patient has inhibited emotional reactions to such traumas, is an important issue that should be considered when working with patients with RA, and perhaps other health conditions as well.

Kelley JE, Lumley MA, Leisen JCC. Health effects of emotional disclosure in rheumatoid arthritis patients. Health Psychology 1997;16(4):331-340.

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Rheumatoid Arthritis and Exercise

This recent study1 examined the effects of an 8-week dance-based exercise program in a group of 10 women with rheumatoid arthritis (RA, Class III). Previous research by the same authors had found that the EDUCIZE program, developed by arthritis researchers,2 was helpful for patients with Class I and II RA. The subjects in this study had a mean age of 54 years.

Both before and after the 8-week program, all participants were carefully evaluated in regard to health status, use of medications, joint pain and swelling, cardiorespiratory fitness, daily activity, and psychological status.

The researchers found that while there was no significant increase in aerobic power, there were other benefits. Social activity increased, and depression, anxiety, anger, and tension decreased after the experimental period. “Many of [the patients] reported significant improvements in stability, improved mobility, and a decrease in pain and stiffness.”

Most importantly, no aggravation of joint pain or swelling was found in the participants.

  1. Noreau L, Moffet H, Drolet M, Parent E. Dance-based exercise program in rheumatoid arthritis. American Journal of Physical Medicine and Rehabilitation 1997;76(2):109-113.
  2. Perlman SG, Connell K, Clark A, et al. Dance-based aerobic exercise for rheumatoid arthritis. Arthritis Care Research 1990;3:29-35.

The Neck Pain Disability Index

This article summarizes a new questionnaire developed by Dr. Howard Vernon, DC, designed to assess whiplash patients. The survey is a modification of the Oswestry Low Back Disability Index. Each category contains 6 possible answers, scored from 0 to 5. Scores are totaled, and a rating is determined: 0-4 = No disability; 5-14 = Mild disability; 15-24 = Moderate disability; 25-34 = Severe Disability; 35-50 = Complete disability. The test has been studied a number of times and has been found to be a reliable and accurate assessment of neck pain disability. The following is a copy of the survey, as the article states that, “its duplication and use is encouraged.”

This survey provides a simply tool for quantifying neck pain disability, and the author suggests using it to evaluate a patient’s progress and to determine severity of disability. Please feel free to copy the following page and use this survey in your practice.


This questionnaire has been designed to give the doctor information as to how your neck pain has affected your ability to manage in everyday life. Please answer every section and mark in each section only the ONE box which applies to you. We realize you may consider that two of the statements in any one section relate to you, but just mark the one box which most clearly describes your problem.

Section 1 — Pain Intensity

    • I have no pain at the moment.
    • The pain is very mild at the moment.
    • The pain is moderate at the moment.
    • The pain is fairly severe at the moment.
    • The pain is the worst imaginable at the moment.

Section 2 — Personal Care

    • I can look after myself normally without causing extra pain.
    • I can look after myself normally but it causes extra pain.
    • It is painful to look after myself and I am slow and careful.
    • I need some help but manage most of my personal care.
    • I need help every day in most aspects of self care.
    • I do not get dressed, I wash with difficulty and stay in bed.

Section 3 — Lifting

    • I can lift heavy weights without extra pain.
    • I can lift heavy weights but it gives me extra pain.
    • Pain prevents me from lifting heavy weights off the floor, but I can manage if they are conveniently positioned, for example on a table.
    • I can lift very light weights.
    • I cannot lift or carry anything at all.

Section 4 — Reading

    • I can read as much as I want to with no pain in my neck.
    • I can read as much as I want to with slight pain in my neck.
    • I can read as much as I want with moderate pain in my neck.
    • I can’t read as much as I want because of moderate pain in my neck.
    • I can hardly read at all because of severe pain in my neck.
    • I cannot read at all.

Section 5 — Headaches

    • I have no headaches at all.
    • I have slight headaches which come infrequently.
    • I have moderate headaches which come infrequently.
    • I have moderate headaches which come frequently.
    • I have severe headaches which come frequently.
    • I have headaches almost all the time.

Section 6 — Concentration

    • I can concentrate fully when I want to with no difficulty.
    • I can concentrate fully when I want to with slight difficulty.
    • I have a fair degree of difficulty in concentrating when I want to.
    • I have a lot of difficulty in concentrating when I want to.
    • I have a great deal of difficulty in concentrating when I want to.
    • I cannot concentrate at all.

Section 7 — Work

    • I can do as much work as I want to.
    • I can only do my usual work, but no more.
    • I can do most of my usual work, but no more.
    • I cannot do my usual work.
    • I can hardly do any work at all.
    • I can’t do any work at all.

Section 8 — Driving

    • I can drive my car without any neck pain.
    • I can drive my car as long as I want with slight pain in my neck. I can drive my car as long as I want with moderate pain in my neck.
    • I can’t drive my car as long as I want because of moderate pain in my neck.
    • I can hardly drive at all because of severe pain in my neck.
    • I can’t drive my car at all.

Section 9 — Sleeping

    • I have no trouble sleeping.
    • My sleep is slightly disturbed (less than 1 hour sleepless).
    • My sleep is mildly disturbed (1-2 hours sleepless).
    • My sleep is moderately disturbed (2-3 hours sleepless).
    • My sleep is greatly disturbed (3-5 hours sleepless).
    • My sleep is completely disturbed (5-7 hours sleepless).

Section 10 — Recreation

    • I am able to engage in all my recreation activities with no neck pain at all.
    • I am able to engage in all my recreation activities, with some pain in my neck.
    • I am able to engage in most, but not all, of my usual recreation activities because of pain in my neck.
    • I am able to engage in a few of my usual recreation activities because of pain in my neck.
    • I can’t do any recreation activities at all.

Vernon H. The neck disability index: patient assessment and outcome monitoring in whiplash. Journal of Musculoskeletal Pain 1996;4(4):95-104. (Reprints of this article are available from Haworth Medical Press, 1-800-342-9678.)

What Does Neck Pain Say to Your Ams?

Neck pain is a common pain condition, and one frequently treated by chiropractors. While patients who suffer from neck pain as a result of whiplash or other injury often are most concerned with recovering the full range of function in their neck, researchers are beginning to uncover how neck pain may impact other areas of the body, including the upper body and arms. A number of studies have shown that spinal misalignment can affect the neurological pathways that create proprioception, the body’s ability to sense the relative position of its parts.

In a recent study published in the Journal of Manipulative and Physiological Therapeutics, researchers based at the New Zealand College of Chiropractic investigated the neurophysiologic connections between neck and arms, and how misalignment in the neck might interfere with this connection. They also explored whether spinal manipulation, as performed by a chiropractor, might restore some of the communication between the neck and arms.

The study participants included 25 volunteers with a history of untreated neck pain or stiffness and a control group of 18 volunteers with no such pain history. Among the 25 participants in the treatment group, 14 had experienced whiplash or other head injury. Most of the participants were recruited from a local university and college area, and the average age of volunteers ranged from 23 to 25.Image of participant position during joint experiment

Each volunteer received an initial assessment from a licensed chiropractor who noted any apparent spinal dysfunctions that might limit the patient’s range of motion. The researchers then measured each patient’s ability to accurately position his or her elbow, using the following method (see image A): As the participant lay on his back with eyes closed, the researcher positioned his right arm pointing up at an 80° angle, identified this as the target angle, then repositioned the participant’s arm to a new resting angle between 70° and 110°. This experiment was repeated with the participant’s neck in different positions (facing front, turned to each side, and pointing down, see images B-D). The participant would then be asked to move his arm back to the original position. Arm positions were measured through sensors attached to an electrogoniometer. The researchers found that the group of patients who reported past neck pain were far less accurate in repositioning their elbows than those with no history of neck problems.

The patients in the treatment group then received a session of spinal manipulation that consisted of high-velocity, low-amplitude thrusts, while participants in the control group took a 5-minute rest period. After these treatments, all the volunteers went through another round of positioning and repositioning their elbows.

Participants with a history of neck pain, who had as a group performed poorly in the initial tests, significantly improved their ability to accurately position their elbow joints after the chiropractic treatments, while patients who had instead rested were less accurate in their joint positioning during the second round.

These findings suggest that spinal dysfunctions may impact the body’s proprioception, especially of the upper limbs. More importantly, the researchers found that this disability could be improved with just a single chiropractic adjustment session. The study lends credence to the notion that chiropractic treatment can be helpful not only in reducing immediate pain symptoms, but in restoring neurophysiological connections throughout the upper body.
Haavik H, Murphy B. Subclinical Neck Pain and the Effects of Cervical Manipulation on Elbow Joint Position Sense. Journal of Manipulative and Physiological Therapeutics. February 2011. 34: 2, 88-97.

Stress, Hunger, and Headache

This study evaluated two recognized headache triggers—hunger and stress. The study participants were 56 students who had suffered from both migraines and tension-type headaches for at least six months.

The researchers created four different test scenarios for the patients: stress, with no food; stress, with food; no stress, food; and no stress, no food. The 56 subjects were randomly assigned to one of the test groups.

When testing the triggers separately, 58% of the food-deprived subjects reported headaches. Previous studies had associated hunger with migraines, yet this study found that hunger can also trigger tension-type headaches. In fact, the researchers measured forehead EMG levels, and found that the “no food” patients had significantly elevated EMG readings.

The researchers found that stress was indeed a potent trigger for headache—93% of subjects reported the start or a worsening of headache symptoms during the “stress, with food” experiment.

Martin P, Seneviratne H. Effects of food deprivation and a stressor on head pain. Health Psychology 1997; 16(4): 310-318.

Overdiagnosis of Fibromyalgia

As fibromyalgia (FM) has gained wider acceptance and awareness in the medical community, this study inquired if any overdiagnosis of the disease occurred in a group of 321 women in a rheumatology clinic. Over a one-year period, 35 patients were diagnosed with FM.

An additional 11 women had received a presumed diagnosis of FM when in fact their condition was unrecognized spondyloarthropathy.

The authors hypothesize on the misdiagnosis. There is an evident overlap in symptoms between the two conditions. The authors compare the two:

“Both conditions frequently present with a long history of ongoing ill-defined pain, associated with sleep disturbance and prominent symptoms on awakening. However, the intensity and localization of spinal pain to fairly specific sites in the neck, midthoracic, anterior chest wall, or lumbar regions in the patients with spondyloarthropathy is somewhat different from the diffuse and ill-definedmuscular pain of FM. Although both illnesses cause sleep disturbance, our patients reported prominent night spinal pain that awakened them from sleep, rather than a complaint of simply restless sleep. Nine of the 11 spondyloarthropathy patients had inflammatory type pain involving at least 2 of these sites.”

The authors noted that spondyloarthritis has a prolonged course, evolving over 10 years. However, radiological changes of sacroilitis may not be apparent at onset or over time. Therefore, physicians can not be reliant on radiological sacroiliitis for diagnosis. The researchers report, “In a 10 year follow up study of 54 patients presenting with inflammatory type spinal pain, all of whom lacked radiological sacroiliitis at study entry, 32 were finally diagnosed with definite ankylosing spondylitis, and a further 10 with possible or undifferentiated sponyloarthropathy.”
The authors stress that FM diagnosis does not exclude the possibility of other conditions causing the same symptoms. “Now that FM is an accepted diagnosis, it is possible that it may be used too freely in patients with ill-defined pain.”

Fitzcharles MA, Esdaile JM. The overdiagnosis of fibromyalgia syndrome. American Journal of Medicine 1997;103:44-50.