Head and Neck Pain ReviewPDF
Head and Neck Pain ReviewPDF
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  1. LI -,t, ,' "''i' t'IC)11 r',rrir,fr of conditutns ar? ireqLtentlv associaled with the oc('uneir(e of lrcacl and nt'ck pain.Tht' purposas oi.fhi.s ro'ieu ,trc: lo desr'rll,,e the characteristtcs oi several ,lru.scu/rrske,/elr/,ncttrololyiL,tl, airr/ svstentir t rtnclitions trr:quently circd as possiblt'cause.s oi ltead and n€.,:i paitand lr.r -slrgge.st ,.' nt'x'tcr'/tnuTuc for tre,rtinp, head ancl nectiK pain. The chtr,tc'tertsllcs o/.mu.scu/c;-slcicta/ onclitrtns, such .rs nrusr'/i. .s/r;rs,?1, lendinitis, trig,g,er poi,tts, and joint rnt'tann,ttitn,and ht'i' relattonslttp fur /te,trJ ,tnrJ rrec,i patn are considert:rl. Thc features ,,tnd cl,inical in',plicattonsol rtcLtrttlog,iL ronditlon.s, sLrch ,ts.rlr.'1;i,tl tactal parn, trigentinal ancl p,lo.;r.tphan,rrr;ea/ ni:Lrra,rgla,relfu.r svnrpalhcltc dt'slrophr,,url neurollent('inilantntatron, are;tlso de.srribcr/. llta distr,t;4uishtng,c/t.rr.tclcri-sflcs r.il.hcac/.rchcs, tncludtny, clustt:r, Iension, chrctnit daily, rebouncl, posttrauntatit , andlrtrsf/trnrlr,tr pun(turc, ,ut'rh'i.ttk.r!. fhlr 'e"it,rv a/.so addressr'-s the cortril,Lttion.s rrf sy.slt,nlrclisonlt'rs.. srir /r ,rs oslt,r.r,rrlhrilts, rht,unt,r'o,;d ,trthrttis and t,he vtrrants, ,1n(l rhcunttoi(l-relateo'ttlrldttttl,ls,/lAt,dt,rnr.t1tlirrttlsi|ts,k'nlptlr,lt,1rIerl|ls,|yntc,.sr1i.se;tstl-trr'r A 1r,trl l!!r tr's17/1.1,1 ,' 1",,'1tl ltilr'l ;'utlt 'l lln'atft'tllrt'nr,rs ;l ttil,,u,r,l,tr'.tl,iltn:ir,,t1.i1,,1/rrr rt'scr/r'lrt,{.\\,rrr)1o/}).s rt'/,tk'd lt.r irt,.rri.in:i neck pain secadar)/ [o nt'urt.t,e,enic tnl-lantnat';on ,t't'pre-se,rlcr/ ln lhii ilrrrl /rc rr',tlt,r circul,rlin,q throug,h hollow ntetal tubt:.s u'a.s plttrecl tntr;torally, I'ori.5 nrinulcs rn llv lxtsltrior rrr,rri//ary ,trea on l2 tndtviduals with r.t'rv,!r'nl patn ,utd /?ru.sc/(,slJJ5nt.ln nrrrt' oi lht'sc rnrlllirlu.r ls, rt'duccd ( lfvleri patn perception, up,pcr trapezilr-s eier;f1lp1ypqi';rp111,sig,n,tl rt'dtt<tton, ,rrrr/ incrt',rscrl cervit'l r,tnp,t' ctf ntotion was prc'ducc(/. -5lr ouf L.tt | ) tncli,,,idualsItad accttntlt,tn, ln,q /re,rc/,rt'ht', r.rhi h i',i,s rt:ducet! or elintinated,in four r'ases. J.irc,se tinclln,qssugg(,-st,r slron,q trtgt'nttnr.r-rr'n'ic,ri rel;ltonslttp b nack pain ancl headache.TKey Words: n,-'ck pain, t'(len)a, intractral '/'(llr1,;C,11Asrrltt.tlt,Pra|'t'sstlr;[)ttetklr,T|t1]Cltnlr,Lt,nle,., l.',r/h.r//,r. Nl'; (./lnu.r/ ,,\s.srrr ialc Protessor, Departrnent ol' Anatcmy, Nerr foil lr4altcal Qtllage,\/.r/ir.r//,r, ,\)'. Ar,/r/rls. lor rt.tr,'prlndt'nct: (:60 Orantat,ut Avt., Mounl Vernon, NY 10552..Fotttldt'rand[)ittt.Ilr,[)txtrltlI[,nrrltnltt'I,,lthokinestolog,y,Nerl,Yor(|/nivtlrsit1''|()',,.:i|991./,ro.ssorand(|latrnl,ln'l)e/l.tt|rltt,nlrll/'ht'slt..t/Ihr,r,tpi,',Netr,YorkLlntvcrsity,,,|97()-I98j;l)ro|i:ssorCc-r//ryc ot.St,rtt'r /i/,rnr/, ('rtr Lnivi,rsiiy oi,\/e,,r )brl, Nerv i'orr, N)'\{t{NIN1,rrL ll. Frieilnr,rnArthur j. Ne lson, Jr.t'u<l lrrrrl rrt'r'k p:rirrrn:* lrt' tlrrrscrl lrt' ltrrrvliir<[ of rrrrrsc'rrlo-skt'lctul ol trt'trr oloeir'rlisolck'r s. Irr lrclrlitiorrto tlrt'st' clisolrlt'rs, :rrr rrrrtlcrlt'irrg svs-tt'rrric t onctition ttt:n lrc srrspcctt'clrr'lrctt lltt p:tirr is ulr('sl)(,nsi\('l.( ()nVcnti()r)lrl PlrvsiCirl tlrc'r-lr1I .N'lrrsr:rrloskt'lt'tlrl tlisor-tlcls srrclt :tsrrrrrs<'lt' lrr'pt'r'ut tir itr' (s1-rusru). tlieecr'poirrts, tcrrrlinitis, arrrl.joirrt irrllarrtrtlr-tiorr Iravt' lrt't'rr sltou'rr to 1rr'orlrtc't'Irt':rrl :rrtcl ttt'r'k lrairr Nt'ttt-ologit: t:<.rtt-rlitiorrs, irrt lrr<lirtg ltt:a<lachc (nti-ttnrirrt', r'lrrstt:r'. tcrtsion, cltlonic rlltill,ot ci;rital. r'clrorrrrrl, l)()st.lrinln)atic,postlrrrrrbar- l)un('tlrl,:'), at1'pical lircialpairr, triet:rnirr:rl lrrrcl {lossolrlian'rr-gcal ne ttralgiu, :rncl lcl1cx sl,nryr:i-tlir-'tir' <lr'str'opln'. Iun'c' ulso bccnsl),.1\\'n to lrt: tlte clirrst' ol lreacl arrrlnt'ck puirr. -l'lrt' s1'stcrnir' < orr<litir.rtts oI()sl.c()artll rit is, r-hcrrurntoicl althritisarrcl rclatccl llrt'trrrrar:oicl artlrr-itis vari-:rn ts, clcrr nrltor r n'ositis, tcnrl,ror-al at -tt'ritis, Lvrrte's rliscasc, ancl flblornval-gizL have lreen inclic:rted as a<lditionals()llrces of hcad ancl neck pain.Alrnost 100 r,ear-s agti, Sher.r-irrgton (b(r) r'cported tliat in the de-2riEt:cr-ebL.rtc t u t, t'xt itutiorr of' tr lJ()fti()nol' tlrc lligt'rrrirlrl rre rrt' "is ttrrc,tLgh t<rcattst' r'clnx:r tiorr ol'tlrt' r'igirl nc:lrtttttsclt s." Sirr<'r' tlrt'rr. t'xpt'rinr,.'rrtsItin t' r',lnlllrrrt'cl :r closc' tligcrrrirrr.,-ct't-vtcul r-clutionslrip ( I ,4.1 ). IJccar.rscthe Xrcad lrnr.l ncc:k :rr-r' ont' Iirrr,.:-tiotlrl trnit, r'cn'icnl nrrrscrrlosktlctalclisolrlr.'r's carr rcli'r' as lrearlac:ltc,.jarr',or-f:rcial pairr-n'itlr or rrithorl n,::ckpain (lt4). l'lre rrrrrlcr.lvirrs rrrus<uk>skclctal nrcchanisrn firr- the pairL iLsoltert stnrctural, irrclrrclirrg r:errlicnlhypro rnobil i tv rl r hvpr:r-r rrr.rbilitv, j oilr rsublux:rtic'n, clt:gt'ncr-alir t' lrorrvch:rtt,qc's, oI I)()st.urlrl, srrch as ot:< ilrir.nlhypcrrextcnsion *ith or ',vithoLrt liir'-warci lrcacl I)oslti()r). 'l'lris occiiritalhlperextcnsion ol the crirniun.l ()n tllccctvical spirtc has lter:n rc:latccl ro ht.'iLclancl ne'ck pain. 1'lris postru'al/l)airr re la-tionsl-rip has rcceritly bcr:n clcsr:riberl tr1'Willfbrd et al (7li) in p<'oplc n,e:rrinsmultifcrcal col'rective ler rsers.Volurne 2,1 . Nurntrr 4. Octobcr llrgti..JOSPTHead and Neck Pain Review: Traditional andNew Perspectiveslv4ark HArthur JFrreclntan, DDSINe/son, lr,, PhD, FAPTA'
  2. Ff G URt l ' Disst'ctton af lateral aspt:r't oi the iace. Al M.rsserer nt'tscle belly t ith oblirlut, /.n erpr/ n1i.s, ./,.r /7irr:r-s(arrow). B) Tendonous aponeurosts oim.t-sscler ntusr'le. C) Deep verlital rrrasselcdrl l:ibt,rs..ltt,n tt,;;5i71, u1multipletriggerpornts.D)Art'alatt'r,tl tothctentporontandibular'jointtrull ,riri,trr,,.,uj.ril7,{f s'nrri.,lrsiipresent.MUSCLE DISORDERSMrrsclc hrperactir,in' (spasrrr) ulrrbe the rnost c()nlntorr rnarrilestatiorroI nrusculo.skelctal paLllol()et, tltatafl'er:ts thc hcarl lind rrcr:k conrplex.Not only can this cctnditirirr causcpain, ltut cltre to thc r:losc rclatiorr-ship of muscles and.joints. it carr alsocause inflarnrnatiol) ol thc joints. Ad-ditionally, bccarrsc ol'r,lre heird anclneck intcrrclatiorrshil;, clrr.onic. r:cn,i-cal rnusclc spasltl nliv als() I)r-ontotcmasticatory nrrrscle spasrlt and vir:c.versa (34).l\ norrnal rnrrsclc carr ltc, clt:lincclas a rnusclet that c:trr l),c contractcdagainst maxirnurn r-esist:rncc n.itlrouteliciting pain (15). I,ain is tl,picalh,produced u'hen this resistarrcc is irp_plied to a musclc that is inllarnecl Lrln spasm. If the Painful nrusclc is ac_cessible, palpating ir for rcndernessnray be uscd to cor-robrrnrtc the sus_pected muscle spasm or inflarrrrna-tion (l:i). For cfliciencv, nitrscles art:i.rsually tested by functional sr()up.lipasrn in the rnuscles that opren anclclose the jarv is identified bv the ap-plication of a ciosing (upu,ard) Ibrcender the cl.rin or an opcnine (dorvn-rard) force appliecl to the incisalJOSPT . \rolume 24 . Number 4 . Ocmber l99ilt'clgcs ol tht' lor.t'r :rrrtt'r.ior- tt.t.tlr.Icsl)('( ti\('l\'. l)rrIirrg tt'stirrg, tltc j:rr^,, isrrriurrt;rirrt:cl ut rrrirlr-lrrrgc., trrrcl llrt. sLrl>.Jc(:t is irrstItrCt.r'cl lo str-orrelV r.csist tlrt.()pcnul{r or. t losirrs lirr-ct. (ill.:l:1,36).For this applit.:rtiorr, tlrt, rrcr.kutrrsclcs carr also lrc ttr.orrltr:<l lx, lr.rrrc_tron: rrec:k cxtcrrclt,rs, r-()tut()r.s, 1l(.t{_ors, alrd latcnrl ilcxor.s. \\'lrt,rr ct,r-vicalrangc ot rlrori()n (R()N,l) is Jtainlirl or.rcstricted, rrrrri;r.lc' J)atli()l()r:\ is srtrlgcstc(i il' tlrc rcstr.i<.tt'tl rrrotiorr r,.rislsin thc rlit'ccti<irr o1t1_rtisitt. to t.lrc ,rr.-tiorr ol tlre irrvolvt'cl nrrrsr:lcs. -I'lr,.r ex_Iunnl('t (:tn lrJ,l)l\ rrltlilrrrrrr rt.si._tar)cc lo thc irrrlicatccl rnrrsclculoup{s) to ver.ilj' this possiLrilitv. 'flrcstcrnornastoid rtrrrsclc, lrou.cvcr., i.stcsted inr.liviclrrallr', lrcr::rrrst. it r:an berclativt:l)' isolar crl (12,13). I I1,1tcr:,rr:rir-itl or- trigccr poirrts in tlris nrrrscle:ofien refr:r as lreircl:lc:lrer, clizzirrcss, or.I:rcial 1,rain (57.73).'frig.ecr J)c,ir)ts ar-c srrrall, isr:h-ernic, tender ltoints irr rrrrrsc.lc thlrtI'eler pain ancl othcr- svnrptorns (71)).Thev are trncletectable bv nrrrscletests, bLlt dtrc trt a lon,er.ccl skirr r,,:iiis.tance over the point, their ltreserrr:ecan be leriliccl bv r':rriorrs clectronicdt'rectors (tj7t. l lrer arc pt.rsistcrrlL'l-'l.ri'(1.\l(,()),f\tt_:il.\R\artd trr:Lv rc-rnairr long lrltcr. th,:r or.iqi-nal patholon' has ltec'n t-lirrrir:,:rte.tlS<trnetinres rnrrltipIcr acljlr<..c:rrt r r.regt.r.points blerr,:1 togerhcr irrl_o ()ni3 l:rr!i-cr, \,ela,tcn,leI arca. \lusticutol\ nrus,r lr tligr-Ir.r' I)oit)ts .rr c li r.r1rrerrtl.,Iotrnd in ltrtrxer-s. irtrlivirlu:rls rr,lrt rclenclr ol qlirrd tlrcir.tcc'rlr. l]:rst,cl ,rrri:lirriciil obs;enltlions ()l ()n(, ol tlrt.arrthot-s, tlte triggcr. llorrrts irr tlrc.st,inclivirirrals llre c()nrnlolilr. 1ty1..,1,.,1,,tlrc rlt't.1r rrr:rssr.lt.t ir nrrr.,r lt, lilr<.r.(FiuLrre lO) in{fr.ior r() tlr(' l(,rtl)()r-()-rnanclibular-.joirrt. Irr arL.Iitiorr r:o r.t._polting pairr, l,rossiltll sccr.rrrrlur_r. totrlgtlctr points, br.trxcr s li-r,r1rre ntlv rlr,_scribe tlrr:ir.jarv trrus<:lcs as fi,t,lirrq"tirecl" rvherr :rsked il tlr<'r' lr:rvc clil1.t rtltv irr t lrt.rrirrr.l (r lirrir.:rl ,rlrsr,tr.t-tion).'l-t.rrrlirritis. sirrrillrr t(I tl.iSll(.rI)oints, oltcr.r pcr-sists lorrg aIlcr tlrt.t'urrse is clirlrirtltterl. I'lris 1;:rirrlirl r.orr_cliliorr rrrav r,t'r:ur irr tlrt, lLlLr.ec rrr:rsst,Iclic :rltont,rrtrosis rrtlcr-ir)r- t() tlr(, l\g()rntrtic arclr (l-ierrr.t' lIr,) rrr at tlrt.t<'rrr1r,rr':rlrs rrrrrsr lt' irrst,r.i,,tr ilrtl:lot'ally <trr tJrc' rrrancliltrrl:u r.or.orrr.ricllrnrr:csr; (27).TEMPCIRONIANDIBULAR ORctRvtcAt APOPHYSEAL folNrINFI-AMMATION(le rrical f ar:ct.joint ()r. t(:rnJ)()r( Fnranclil.nrlar join t irrl lant1 uIrtt( )n (.lu Igivc ris,e to loc:rl ancl/or. rr.lflrr.t,rl1rain. T'enderness o1'tlre joint to pal-patlolt, and restrrcted raltgC ol'nro_tion <lue to pairr, rtill trsrrallv idr:rrt jlr.tlrc inllarnc<l .joint. An inllarnccl terrrp()lr)rnan(libtrlar -joirrt rvill prcsentwith tcnclerrrr3ss to P:rlpallon or,,:r- it.slateral rrrrd//rtr posteri()r nspcc.ts (3ir).The erxurnirr13r palp:rtes tlre later-:rl:rspect of t lrc ternp()r()lla nr libr,rl :rr..joint br, ltlacine tht' rip ol rlre Ior.e1lr._ecr.Just anterior Lo tlrc. trir{,lus o.f tlicear. As [hc ir-rdividual opt,,ns tlri,mouth u'icle, the cxarnincr's Iirrq,:r.rvill identill' a. deprression ,lverlvingthe joint that is created br, 116, 1..,,,.-latirrg trlrtdylt.. Postt..r ior t(.ll)l)or ()-rrrarrdib,llarjoirrr p:rlpatit,l1 i. prr-269
  3. ct. l\lC.\l(.o\1\{F.N1'.\R\Tension headacheconstitutes up to 70%of headaches,occurring more oftenin women thanmen,lirr.rnecl lr'plucing tlrc tip ol tlrt littlcIrngcl irr tlrc patlcItt's cxtt'r'ttitl attdi-lott r lilLtl :tltrl rlcllittt lttttt ti,)l l)l( \-srrr-r' :ts thc p:rtit'rrrt r t'pt'ate tllr' ()l)el)s:rncl c lost:s his,/lr,:t rttorttlt (3I ,33,3ir).F or- t:ortt1-rtt'isort attcl t'xlrcclit:rtt r',lrotlt littt'r'll ltttrl ltostt'l'it)l- t('lI)l)()l ()-rnanrlilxrl:tr'.joirrt lxrlltlrti()ll :rl-(' I)cl'lirrnrccl LrillrtcrallY ltttcl sitttttltlt-nc<.rttslt.lrr arlrlitiorr t() t('tl(lctll('ss, tlit'lr( utcl-v irr{larrtctl tclrl I)()r'( )IIrltltrlibttllrl'.joint is cluttat'tt'tizt'rl lx tr plrilrlirl It'-strictt'tl .jarv opctrirru, lttt opcttitt{ cle-viatiort tou'ltt'tl tlrt' ltlli't:tctl sirlc, arr<l:r disnrlrti<lrr oi lltc ot't:lrtsiott rlttc ttran inll:tnutllt()11 ('xr.tcl:Itt'.'flris extr-<latc is olictt tlt'rttottstrlttt'rl r-aclio-graphicallv bv lttt itrt t citsc<l itt(t-:t-articrtlar- syrac:e . liou'cvt'l', i{ tllt'inflanrrtr:rtiotr is t:hr<tltit:, l2ttcral t('l)-rlerncss to pallration tttav lte thc <trrlylin<line. In citlrer- cast', 1;lritt Ittav lltrrefcrrecl lis ternporal Itcatlacltt', cat-erclre, ot- jau' lrairr, atrtl sci:otr<iatlrrrust lc s1r:tsttt :tttrl :rdilttt'ltt tr irlgt'rpoints llla\' ()ccttr itt thc rnttscles olrnastication (35).Unlike ntttscttloskclctal conrli-tions, thc lirllorvirrg tteurovascttlardisorders calr cause {irlrctiotral lirnita-tions, whilc not clircctly lelatcd tt.rIirnr: tional activities.'I'heser cotrclitiotrsmust alst.r be colrsidcred irt tlic clilfer-ential diagrrosis oi' lrcacl artd treckpaln.HEADACHEMigraineN{igr:rine he':rdache is fbrrnciequallv distribut.ed anlolls the sexes270inin clrilcllr,ood, brtt trr'o ottt of et'elr,'tltr-r'c aclrLlts rvitlr nriqlaine ltearlat'ltesalc \\'onr('n. Thc tt'r'nis "c()IIlllr.()rl'lirrcX "classic'" rrrigr-:rinc liave llct'tr t-c-plar-'ccI ll "rnigr-lrirrc rr'itltortt altra"arrcl "rrrigr-airrc willr uul'u.,' lusl)('c-tir'elr,. l\'liqririrrc witlrottt :rttt a is cle-sclibed lrv tlit' Irrtclrtationirl Hlcacl-lrc'lre Soc rLetv us an irliollrtliit r-ectrr-ririg ll('a(laclre clisoltlcl rttarriflestingirr att:rckr, lasting'1-72 horrrs' ('10).Ir'1rir':tl trrtqnrtttt' t ltltt:tt lt tistir'. :ttt'ul)il?iteral lot:ttiott (fi0(,li ol t:ascs),ytrrlsatirtu tlrralitr', rtto<lclltlt' r)l scvcrcilttt'rtsitr'. aggr-lIvltti()ll ltt' r'orrtirrt' ltltvs-i,ual il(ti\it\', lttrtl ussocilttiorr tvitlt tt:rtt-st'u, plrotoplrolria, lttttl phorroplrol>ilr(,10.ir5,61,1,).'fhc alrovt' svnrl)I()rlrs ar('tlrt' sarnt' Iirr- botlr tr'1rcs ol tttigt-aittt',lrtrl IttiLlr,tirtt' u'itlr :rtttlt is 1:'tcct'clt'cllrY rrt'rrr'ologit'ltl sttttyrtottis r'tti lt ltsrlisttrlbt'cl <lisloltt'cl vistt:tl itt:ltqt's ortirrglirrg. rlvst'stlrt'tic st'rtslttiotrs oti tltt'plrllitt', [:lt c, or' ;rrrrr. -l'ltis tr'1rt' ol rtti-r;r'airtt' ()( ('ur'fi irr I0-15(,{, ol irrtlivicltr-lLls tvlto lutvt' Irrigr':tirrt's ({(t.:i0) .Cluster fleadache(llrrsr.t'r' lrcuclitt lrt' is tlcsr:r-ilrctl :rslr s('\/cl e rrrtilatt:r':tl r t'tro-orlrit:rl hcttcl-achc, oltcrr :rt'corttlltttit'rl lr1 Iraslrl<:<>rrqt'stir.rrr lrncl clist'lralut' :utc[ lltosisridr-ooyrir re cvclirl) ott tltt' svrrII)t()lrt-lutir:'sirlc (Ili.irir). ll ott:ttls I:rtotc lLc-(lrr('ntly iti tttcrt tl)lut itt $'otttctl. LItt-likt nriglainc sulii'r'cls, u,hr lcclrjLrligcrl t.o lic ckrrr'rr clrrrirte; a s('\'erclreaclar:lt t:, tlrcsc i rr <livitlr.rals fi.:t:l bet-t-er clrrrirrg a heaclacltc bv rcnrailringiLrr :irt crt'ct p()stlll c tttttl trr'll'ittg:lborrt. ( llrrstel ht:atl:Lcltcs t>t cttr irrgr()lll)s ()r clustcrs, olit:n at lirc santetinit-- oi <1a\', ovcl a pcriocl of rvceks,or rn()nths. Thc <laily bor.rts of'head-;;rclrc rrsrrirlh' srrlrsirlc urrcl tlrelr clisap-pear, orrlv t() le()c('lu' rrftct' :ievcraltnontlts o1' qtricsccttcc ( l8l.Tension Headachel t'rrsi,,n lteadltt ltt' c,rttsliltttt s ttpto 70ui 'rl lreadat ltt's. occtttI tllq lnor'('ofr.cn irr \\,()n)en tltatr in IrLe ll (13,25).It is clurracterizcci b1 a stel,iy :rche inthe li'rlrrtal or ternpolal areas anrl isnot rrsualll' acr:ornplrrrie<1 bv thcs)'nrplolns of rnigraint,' or- r:lrrster'hca.dache ( t3,25 ), altlrousli phol,o-phobia or- phottopit,lbia rnav or:crrrdrrring epis,.rclc's ol' leusion hcarl:rche.l-r-'nsion lre :ld:lches alc rrsrrallv bilat-cral, sonretinres slrrrounding thc'hcacl like a "b:rtrrl." Pt-t-'r'iottslv t alleclrnrrscle c()lrtr:it tion hcatIat:ltt'. tltcternr has beerr cltattgt:cl bt:caus,:: ttcrt:orrsiste'nt associlrtiort bcnlccn tlrisc.rr<litir,rrr alrl rulsr'lc |1,111'r-activitrh;rs ileen denr()nstlu.t('(l.Occipital Headache()cr:ipitirl lrearlucltt' is olt<.'t'L ,:1e-sclil>c<l lis a tlpc ol t<.'ttsiott ltt'uc["iiclrc, lrtrt ntattv r:lirriciurrs l,rcl thattlris conclitiotr itt tlt,.: ot r.:ilrital ot sttlr-()r:'('il)il.ul legion o1'llre' sktlll is r:t:rli-cogcrri<:-reli'r'r'r'rl 1-rlrirr llorn lr c't'rli-<'al rlisr.,t'rl<,'t- (21,39,77). \\'ltt'tt<'<.:rlir':rl Ir'AL:tl()ll, t-t'rlr.tcinq tr't'i!;ltt. otitlrc crrvical syrirtc, tcrrrpot:uilv tlt'-('r'eascs ocr:ipital ht':trlat'lrt' p;rirr, itsultgests tlr:rt thc ()r ciPital liclrclaclrcis a lesult of rt:li:r'r't ci pairr fi-orn ,tc,:rvical clisorrlcr (it4).Chronic Daily Headache(llrronic <laily lrea<laclrer is clt:-lirrecl as a constlult tt'ttsiott lrt'lt<1;,tclit'H'ith nrigrainotts cx:l<'et'batlorrs ( ir3,65). Cihrorric rlaily hcarlacltc trrrtiillver'<>h'es over tinle lic,rrr cytisotlic rni-gr:rint:, but thc cauric is still corrtro-vclsial. Indivicluals sr.rflerirtq Ii'-rtrrchronic daill' lreaclirt:hc Ir-crlrrcIr ti1'sLrller h'orn rebound hearl:rcltc asurell. I{el>or,rrrd liea,:laclre i:i tlte *'or-s-ening ,3f'head pain in chlonic lte ircl-achc sr.rffcrer-s. It is c:tttserl lrv llie fi'r-'-que nt and ext:essive usc ol' e r-gots zul(lllonrlat'cotic analgt,rsics (4t,) .Fosttraumatic HeadacheIrr additron to tlrt: illurlc{liirlepain lirllowing a ht.acl itr.jLrrl', 1>ost-tr'zrlun:rtic ht'adacl]c. a Inorc pro-longed and enduring he:trlar:hc, mavVolurne 24. Number 4. Or:tolrr:r l9!)6..JOSPT
  4. clcvcl,rlt ((ii3).'l'his conrlition. r.(.:i(,nr-lrlirrt t'itlrt.r rrrigr:rirrt' r,r l(.llsir)n-l\l)(.Ircarla<'lrr', nlav l:rst Iirr. rr.ccks..r)()lltlis, ()r' \'citrs (ir5). Jtt rrltr. ulso ltt,ltss,,r i;rlr.rl rrillt 1r,)\ilr:rttrn,rli{ \\u_d.r'r)ln(.. rr'lrir lr irr, lrrrlt.r :r \:u i(.t\ ()ls\llll)t()ln\ \lr( ll :rs ir.r.it:rlriliri, ilrst,rrr_ttilt. trtrxit.lr. rlt.lrrt.isi,rtr. ;trttl rt,rlrr, t.tlabilitv t() (.()ltcelirl.ute ((,ili).Postlumbar Puncture Hr:adachel-lcvcrr I)cr.(.('rlt ol lri),(X)g l)uri(,1)rsrvho Itarl :i ]rrrrillrr I)ullctul-(. r.r.por-lt,rlItavine l)()stlur]rl)ar Prrnr.trrr.t, Ircurl_aclre (7ir). N{ost ol rlrt,st: lrt.:rrlut.lrt,sr(:sol\'o tlLrir klr', lrrrl sorrrr, ltt,r.sist ltItt.r.7 to l2 ni()ntlls.Atypical Facial painAtyltit:al I:rt.i:rl pain is t.orrsirlt.r.t,rllt1, nurrrv rrc'rrr.oloeisls lrs lr rrt,rrr.ulgilrr:harac'tt'r'izt'rl ltl tr'1tir allr.. rrrril:rtcr.:rl:rrrrl lt'lrrtirt'l\ ( ()nsl,llrt Ilrt ilrl lr.rirr(6tt), u'lriclr is rrnr.r.lrrtt,rl to.j;ul firrrr._tion (2tit. llris r onrliliorr. rt.r t.rrtlrlt'r l:rssilit'tl :rs I:rr i.rl p:rirr lrr tlrt. Irrtt.r_,lior r:r l I It'lrr llrt lrt. S.r it.tr , is rrol,rt'll rrnrlt.r'stt,,,rl ltrr,l,rllcrr rlt.lit,s ;rllrrrr.rclcs ol ll'clr(nl('ltt ({0). \Jlrrrr. :rrr_tlr'.rlitit.s lrt.lit.rt. tlr:rt l:rr.i.rl Irrrirr i,l)syclt()s('ni(' (23,(;8). l{olr,t.r.t.r.. ir IursLcr.:ctrtlv llccrr rclror.lt'rl tlrat irrlr.aOr.ltlcclcrnir al)(l 'Ir-igcnlirrul \'l rrcrr.r. rlis_ItiIlttlit)It :rtt.:t lt.ttrlt.r n(.ss \\(,1(. ( r)n\i\_tcrrtlv {irrrnd irr irr<livirlrurls u.itl) :lt\.1)i_cal laci:rl ltain (2(i). l,-rrr.tlrt:r.nror.t,,tlrt:se inclivirlu:tls cxpcr-it:nt.t.<l r.t,licl'ol their s\/ntJ)t()llrs irr r.cs1:ronsc to lou-levcl helitrrn-rrcon lust,r- tlrt,r.uJrr (l]0).TRIIGEMINAT NEURAIGI,{Fre<lrrcntlv r-cli'r.r.crl to as tic rlotr-lourex (.18), tr-igcrnirral rrt:trr-ulsia is arccurrcllt, iclct0ltatlr ir.. ltlrrrrxVstrLrl.rrnilateral fhc ial 1lairr ()(.(.iu.t.llle. ()\.(,r()r)c ()r rrror-c rlivisiorrs ol llrc tr.igt,rrri_nal nerrc (48,71). It is cli:rr.iictcr-izctlb1 lrricl cPisodes ol scvcr.t. 1r:rirr.rvhich :r'e separatc(l ltr' pain-lr.cc pt,r-i_ocis (48). Thc cpiso<lt:s ol pairr urt,r'+ie n trigqerecl bv inttocrrrtrrs ()r-g(,n-.nechanical stinttrli to hr.ltcr.serrsi_JOSPl' . \Iohrrrre 2,1 . Nunrlrcr.4 . Ocrober Iggtitlvc lugecl' trlclrs. -f lris cortrliti<trr rl:tlbc' irriti:rtcrl l;r' rtllrtivclr rrrrt.orrrpl _cirlecl clr-'ntal 1rr-ot.t,rIrrr.t,s. (.:rr.lr:rnlr,,_cpirrc (l'cer-ct()l) is tlrt, clr.rrg o1'clroicr' lirr r.r'lit'rirrg tlrt, lrlrirr ol.tr._ee nt i n:rl ll ('r.l r-lll,Jiilr. IJ orr.t,r c r.. I r.rrr g,t(,lnl us,t'ol tlris clr.rrg t.:rrr lt,rrrl to Pr.t,-nllltur-(' nrr.'rrtlrl lrrrrl ltlrrsir.al agirrg(71).CLOSSOPHARYI\GEAI- NEURAI-GIA..\ r't'lutivclr r-ur-t. clisor.rlt.r . glossl,_ltliltrlrrgt'ul rrcru lrlgilL (.irus(,s Pcr.iorl:;ol st'r't'r't' st:rltltitrg Ptritr sirrrillrr. to tr-i_gt'r rrir lrl rrcrrrlrlgilr. I lox,t.r.t.r., rr rrl i kr.,trrgcrrrinul rit,rrr-lrlgi:r, llris r onrlitiorr(:rus('s plrirr irr tlr<. llrr.o:tt. lr:rst.ol tlrct()lleu(', tlrr., trrrelt, ol tlrt. rrr:rrrrlilrlr,, rrrrrct k ((il)REFTEX SYMPATHETIC DySTROpHtr,I.'r't'r1 rrt'r r I lt. lrssot.i:rtt,<l rr.i t I I t I tt.('xlr'(.lnltl('s, r.t'llcx slrrrlr;rllrt.tit rlr.str,r_lrltr trr.tr :tls,r r,, r rtt itr tltr. l;rr i:tl ;rrt..r.I rlrir :rllr, r't'flt'x :;r'rrrp:rtlr(.li( rlrstr.oPlrr ,rl llrr. l:rr t. i. t lr,rr:r, rt.r izt.rl lrrr otll iltttotts. lrot. t ltr, rlrlrirr,g. lrrrr rrirr,S1t:rlr associlrtt,<l tvitlt \trs()ln()t()1. l)ll( -r)()rn('nu. -l lris llrirrlirl r.orr<litiorr t.:rrrlrc tliger:r-t,rl or. r-rat.c,r.llrtr.<l lty liglrttorr<'lt or otlrcr- st irrrrrli orr tlrt. [:rc.t.(51,{;0). lt rrr:r} lollon. tr.:rrrrrrlr, r.r,rli( :rl ()sto()lu tlrr-itis. or. sllr.g(.r.\.. Irr lrrlrli,tl()n t() tlrt' ltairr, ;rssor.ilrtt.rl slnll)t()nlsol snr':rtirrg ltrrrl r.olrlrrt,ss ()r. \\.:u.ntrrrrrl rlr-r' skirr ur-t'li:; rnu\. ()(.(.ur- (5 l,(j0).RHEUMATIC DIS]EASTSIi.lrcrunlrtir: rlist.lrst. r.urr ltt. tlt,-Iirrctl lrs arrv ol st'r.1'1'111 i or r<lil iorrs< lranrc'tcrizccl lty i rrlllrrtrnlllti()rr tul(lpallr rn rnrrsr.lcs rrrrcl .joirrts. l.-ir.c rrr:r_.;ot' catt'gorics r,l r.ltt'rrrnatit. tlist.trsc('()nstitut(' tltr. or.etrrrit. nrrrs<.rrl()sktlc-t:rl ":rr'lrt.s lrrrrl 1r;ri.r." irr qrt.;rtr.r tlr:rrr1)5!1, ol all ltatit'rrlr: rr'irlr rlrcrrrrrirlit.clist'ast:. -I'lrcr' urt., irr or.clt,r.o{ ll.c_(luenc\'()I o(.curr-(.r)(.c: 17 soli tissrrct lrrrurr.rlis,rr. J, rlt.qt.rrt.r.,rt ir r. j, ri11 1rlist'usc, J7 irLllarrrrtraton, r.lrcrrrrraticrliscasc', 4) u<:rrtc. rrr()n()iil.ti(.ular. ar:thritis, anc[ 5;1 collrret:rr r,:tsc.rrlar. clis_(it.t:\tc.\l( ()\t \t t,\1.\R.casc. Sol.i tissrrc r-lrlrrllrtisln (lrrl-sitis.tcntlirriti:r i. trsrr.tllr llr,l \\\l(.tni(.:rtl(l t))()ll{):illi( lll:u ilr llil iti,. 1r,,,1,,,,,.,-gt'rr vasr:rr.lar rliscasr, :Lr.t, r.r,llrtir r,lrt'art' (7). llrcr-clirr.e. <lcgc.rrcr.lrtirt,. join t ilisr.ast' u rrcl i n f llrrn rrr lr1 or.r. r.l r,r,rr_tnlrtit rlist.lrst' rr.ill lrt r.rrrlrlr:rrizr.rl lrcIrxr'.-flre' genclal tr,r.rn Iir. irrlllrrriulL_tiorr of :i.j,rirrl is lu.tlrr-itis. Svrroi.ilrl(rrror:rlrlr.t joirrts :rrt. lirr,.,l .nirlr .r tltrrrsvrrovitrl lllclllil)r-iu)('. n,lric.lr is tr1tir ltllrtlr(' stnrctul t' []rlrt is irrlllrtrrr..,:l itr tLrraltlrliti< .joirrr. l'lrcr-cfirr.t,, rIrt, spt,,L.ilir.t('r-l)t I()t' st'rr0r,ial nt<trrrltr.:rrrt, jIrIltrtlt_rnatiorr is slrrovilis (l:i5), rrltlroLrglr rlrr.rrrtt,r'nlrl srrrllu.r' of tlrt..joint t.:r1>srrlt. is:rlso inlllrrrrt'r1. .,\ rrrt,rlical lrisrorr,sltorrlrl lrt. olrl.rint'rl lrr,111 1lrr. irr,liritl_rurl rvitlr :rn irrlfl:rrnt.<[.joirrt(s;), lrt.<.,rrrst.ct'r'r'icirl ()r' t('ln [)()r-()rrr:rrrtlilrr rllrr-. joir rtsr,rrolitis rrlrr. r.t'llcct :r svstt,rrrir. r.orrrli-lio1l ;qi,,1r1,r,st.tl t,,,, 1,,,,t.1r 1111., l1;1111_< lrl Jrr'olrl<'lrr (ii,1). I.or. t,xlrn.r1rlt,. lrllrrrrilv Iristorl r.rl tirllrr.itis, plrirr irrotlrt'r-.joinls, a skirr r-:rslr (1rsorilrtit.altlll'itis), or rrror.rrirre stillircss rrrir;lrtirrclicatc syst('r)lj(. inr.olvt,rrrcrrt (ll,(i).r\r'tlrIitis clrrr Ilc clivirlr,<l il)l() t\\.o e(.n_t r':rl t :tlt.qrrlir.s lltt. (lr.t(,ll(,t:lti\(. l\ l)(.irr nlriclr tltt' ltr.irrltrt l)trtll()l()a,\. illr'olvt's tlrt' ur-tic.rrliir. cartil:lq(., trrrrl tlrt.irrll:rrrrnratort t)'p(f, irr whiclr tlrt.pnrblcrrr irs itr thc svrrtl.ial lrrr.r,r. of llrt,.joirrt t':rpsrrlc (l3J).OSTEOARTHRIIIS()stc'txrr tlrr.lLtis, corrrrrronlv r.:rllt,rlclegcrrctr-lrl iVc . joi rrt rlist::rsr,, ( )t- ()stc()trr:llrr-osis, is lr puilrlrrl <:otrrlitiorr c.llrr.:rr.._tcr-izr:c[ lr1' a tlrirtrrirrg of tlrt. :r]-ti(.ul,,rr.c:ur-tilagc :t.n{l rurr.rolvirrg ol tirr:.joirrrspuc'c irr in.l'olvcrI lir-l.iculati()ns. -l.ll(,Ilritislr <:ull it ostcoar.tllr.()sis to clistirr_errislr it 1)-ont inllarrrrnirt()t1,,:list,trsr,.Itrll:rrrrrrrlrliorr i: not tlr<. lr:rllrn;rrl oltlt'gcncnrtivt'.ioirrt rlist,lrsc, lrrrl rr scr.orrrlarr', olicn t:vr.lical, ltlrcrrorrrcrrorrrlrrc to tlrc thinning ol tht: urtit:rrl:rr.ct2lrtilaee ancl rrarr-oivillg ol' tlt(, ..i()in1spuct'. In a,lh,:rr r<-.,uri cllscfi, tl)(, ctrrli_lage rnav actu:rll)' ltc tot_allt, cL:51.1-1.,r...,1.()stt',r:rltlrlitir lrairr (,( ( lu.\ il tlrt..joirrtbecorrres inllarrr,ccl or if the nrtu,'.2't l
  5. ct.iN IcAt- co\lllL-\ t .\R\closclv approxitttatcd bonv sttrfaccsrttir tosethcr drrring lirrlcticln ((l'45)'Iur-ther', itt cascrs o[' ostcoartlllitis thatinr<rlve tltc tctnporotlanclibrrlar-.ioirtt,the disc in tlris.joirrt carr becotrlc ciis-Iocatccl, inrpirte,--cl. or clelgctIcratelcl,catrsing Iirlthel joirrt s1>acc 1l:lrl'o\\'-ing. ln sevcrc cascs. signilicant radi(Feraphic cltangt':t tlllrv llc seert itl thcmirn<libttlltr con cii'lc ancl acl jacerttsurfaccs of'thc l.cttrprtr-al llonc (35).INFLAMMATORIY ARTHRITIS-I-ltt' <'ltlegotl oI' irlllarrrIlrat()11'lirtlrritit' t'ottrlitrotts int'lrr<lt's :t u'iclt'r':rt-ictr' o1' tliscas;t's, Ittatrl ol' rvhicir alcsvstcrrric itt ttztlttt-c. 'fltc lal'gcst svs-tcrrric ar-tltt-itis grorrp is llrt'trrrtirt<li<larthlitis (7). l.iqlrtr l)cl'(rcr)t o{ irrrli-r.'irlrrals rvitlt rltctttttlttoirl irrtlrritis or'one o[' its vat-iltttt cortili(iotrs r(]l)()rlItt ltrl ,'t tlt ( k pltitt .tt s,,tttt' p,,ilrt itttlrc r'ortt-st' of'llrt' <list'ast'. 'I'llt' ltt'lr<lanrl Itt'ck ltairr t'x1rt'r'it'ltt t'rl lx tltcst'inrlivi<ltrals is rrstrltllr' (ltl(' t() irrllltlrl-nrati()ll ol <'r':tttial :rncl/ot- ccrr"icltl.joints tliuut:r't'tl. lrl tltt' I-ltcttlttlttoi<1arthl'itis. Fttt'tlt,l't, thc l'lt<:ttltllttoiclriisc:nst: I)l'()(css ttt:tr' llroclttcc a Itr'1rcr-plastic svtrovial lirring (llanrrrrs) irt tlrt'involvccl .joirrt (rt). l'hc patltttts t'attgrorv ittto tlrt'.joirrt arrtl ciisrirllt {irnc-tiott its rr'cll iis lrlorlttct' (artillle('-cl('-str()l'inq eltzvlllcs (3'1). \tlrliartt lot'tltsol' rhcttttt:ttoitl ar-tlrlitit cottrlitiottsincltrclc.jtrverrilc rhcttrtratoitl artlrritis(19,t4), psoriatic arthritis (l0), anclzrnkylosirts slltlncll'litis (5).'fhesc <lis-r.rr-ciers, I)artictl I arh' att kvlosi t tQ s1-rtitl-dylitis ancl .juvenilc rltt'utnzltoicl ar-thritis, cilll catlse ccrvical pairl llvcreatiltg cctliclll strtl(ltrlral llroblenls,rvhich m:u colttlltonrisc tlettt-al strttc-turcs, such as It('l-\'c roots ()1' thc spi-nal cortl (l'1,17). Lrrpus ctlthclllat(Fsis, usttall',' cl:rr;silrccl as a t:ollage rtvascular diseasc, Ina\.' alsc) be consid-ered as an infl.antrnatol) arthriticconclitiort. Thr: itnurutle conrplexdeposition chirracteristic ol lupus elf'thematosis catrses the svnovial sttr-faces to become irtllamed ('1).272ADDITIONAL SYSTEMIC DISiEASISDermatomyositisr\ svstcntic cottclition t,f tttikltorvtloligin, tlt'rrtintonrvositis is :ill inflalrl-nlittor1' r:onclitiort Ol skcletal lllrlsclc.Tlris corrclition is :tssocirlt('(l \\'ith afairrt lillr,-r,,lott'tl t.tslt t ttrl'littq ottthc Iact'. irrottttrl tht: ct'cs, :,tt<l stitttc-tirncs orr tlrc tiot sttrrr ol tl'rc ltatrcls,t'lborvs, ancl tt-tutk. ltr arlrlitiort t<rnluscl(' rvcltkttclss, Illllscl(' t lta.ttgtlsttrat' itrvtrlvc' Itttt tosis. Illl-osis, chronicinllntrrrrur(iott, irtttl ttrrrltilirc:al clcctro-rnvouluphic: cltltttgt's. Irl arlditiotr toits c'{li'ct ott trittst lcs, (lcfl}l;tt()lllvositiss()nrt:tirncs itlr'olvt's.ioilrts, ( atlslnlllil ti('ulaI cartilite(' ( I('strtl('r: i r)t I llrtcl/ orir-r'itati<,rr ol lltt' svltoviltl ttt,.rlttllratrtl'It'arlirt-g to st'ttovitis (8). l'ol;'rrlr,ositisis sinril:Ll to rlct'trtatotrrlositis irr all ol'its nranifi'stittiotts. lrttt rvitlrrlr.tt tltcr-uslt. 'l ltt'st' t'oll:tgt'tt tlist'ltscrs 1lt'o-cltrc't' r'ir|ottic' ittllltlttttllitott lilttl clt'-gr.'rrt t'ltlivt' t ltltttQt:s o{ tlrt' :;kirr lttrclstli:ttctl skt'lt'trtl rttttsclt' (fi,7(')).For comparison' ,andexpediency, bothIateral and posleriortr:mporomandilinularjoint palpation areporformed bilaterallyand simultaneo,usly,Temporal Arteritis'lcnrpor:rl ar-tclitis, :rlso calledr;iiuit< cll arte litis, lr'pic:r1.1'1" trccrtrs itrinclivi<l.uals orcr' (iir vcars o{'asc. Ther ottslt llali,)ll ()l s\llll)t{,lll\ s('('ll illtcmp<,ral arte ritis inclrrdc:i headacltesIoss ol b:rlance , rltlublc viiriotr, andpuin on chewing. Itt tn,rtt,'' ,lf'these<:ascs, palpation o{' the tt'rnporal areasitrpcrior to tl)e zvg()rtratic arch mayclisclosc :r thickcned tortlroLls temPo-ral errlr:ry' (3). rvhictr ciur be iriopsicclfor corrfirnr:ltion tll t-he conclit.orr.l.ches irnd p:rirts trt:r',' ouctrt- :tll o'icr'thr: bodv duc to pr.rlvlnvalqi:r t-lrct-t-nnirticu (22), a cottditiot't that a.pltearsclose'11' relatt'cl to tcrnp()ral artr:r itis.Floth conditions are cltarac:terizt:d itt'a. high sedtntettrtati,:)]l ratt'. Tertrprorala.r'teritis is pt'esent irL alttltrt 20 ,rc ofpaticnts lvith polyntl'algia rh<'trrnatica,aLncl both <:otrditior:Ls respond lapidlvto it st:tn(larrl lreatt't-.etlt coltsistirtg o{zL sterroicl regit-rtt:. I{' rllltrcateci, tclllp()-ral artcritis <:atr rcsttlt itt sttclcitltt irt't'-versible bhnclnt'ss, causcil ltl tltltlllr-bosis of thr.: ophtltalrrric nrtcrilrl s)'stcl)).Lyme's DiseaseL,1'rnc's tlisc':rst'is cltusi'rl t,1 a spi-rochct.c, B<lrlcliir lrttrg<lot'{eli, :inrl isrLrarrsnritted l-l1' thc lritc o['atr ilrl'cctctltick, restrltirru itt lt clrar:l<:lt'r-islir: skinlcsiott. '['hc svstcttt'i( (]()lI)lx)ne llt ()l[his <llscast: cttttsistcItt.lv itrvolrt'shcarlachc, .joirrt plritr, ltrttl Itlrtst l.c:pain (2). Sittce Btrll's Palsv is {r't'-clucr-rtly sectt itt cttrst,'s o1 [.'r'rnc's tlis-c:rse, indivi<itrals tltrtt l.rrcscrrl rvitlt1:rc:inL ntuscle wcakr,t:ss shotrlcl l-,t's<:rce trcd [<rr othcr sitttts :ttrtl sllltl>-totns ol' f,vtttt:'s clist:asc. JFor cxalrrplt',lircial nervc cxt:it:rbility catt lrc tcstcclbilatr:rallv, ut.ilizirrg thr.: lllirlk r-cllcx<levcl,.rpetl lrv Kugclbcr-g li47) anclcclrrf it'nrr:<l l:rv Ruslrtvot'tlr (62). fhistr:st dcnronstrates chzttrgtrs in tllc al:li:retrl- c()ln[)()ncltt lrl' thtl tl-ig,::rninaIlrcrri/e, thc clI'cre lrt 1-)oItiotr ol tirclatial nt'l'vt. nl1d rl.t' lrotttittt' I)ol'li')llc,f the bnrin stent. .\lso, cltlrtrqes ttrclt:cl-rical aclivit)' li'onr thc trltrsr-:les ol'fa<:ial exprr:ssion r::ttt l-re rle tcc:tccl i-rl'rrce<l le <,'ler:tronr1',:rr3raph1 . Srrchchartges in clectlical activit\' ,,:nIl lrtrincli,:at.ivt: ol Iircia.l tten't: dcgcttera-tion (9).FibromyalgiaIndiliduals srrf l'eri nr4 li-orn fibro-rny'al;qia t:ornplairr of' rvirl,:s1trr:lrd rntts-t:rrlar p;Lin a.ntl stiffness. fltesc cirar-acteristic syrnPtorns are ttsrtirllv morese\/ere in t[e rngrlirrg :Ltrcl duringV,rlr.rme 24 . Numbcr 4 . October 1996 'JOSPll
  6. I.|cURt2'Thr,apir,t|art'.to||fnl,t.rt||,trl,.||llrdnltl|,;rcervic;/ musck, hy,per,tc|ivitv ,ut(l p,1tn.Itrtrrricl wcatIlor'. -l'lo otlrcl t orrsistt'trtIirrclirrgs irr Iilrr'orrrt'algia :rr-t' rrt'r.kp:titt lrrtrl rvi<lt'sprt.:rrl lr itr.tt.r lloi111q.-['hest: trisgt'r- Poirrls an(l l)('( k l)uillssociittccl rvith Iilrrorrrvlrlqia tr'[ric:rllrrcsponcl to lrhvsir':rl tht,rupv trcut-rncr)ts, sucll as spr':rv urrrl str t'tclr (7!)),rnicrostirntrlatiorr, :rrtrl nlrss:rg('. 1\ltti-ittflaililrtlr(rlrt rrrcrlrt :rli,rn i\ il()l usll-arllv cllcctivc asairrst Iiblorrrvirlgia'srtrtrsculoskcl(:t2rl svn)l)t()rrrs. Ilt'clrrrscindivicluals u,itlr Iiltrrrrrr.',uleizr Ii t'-qtlcntlY exJtcrit:rtt c lr sl,.'t'P [)trtt('t nclisturltancc' (7tl), arrtirt,l'1)r('ssallts lu'('oltcn usccl irr tht' tr-cllrtrrrcnt ol'lllrr-<rrnyalgia becnusc thcsc rrrt'rlic:rtiorrshclp trt rcgulat(' tlrt' slt:cp l)att('rn.NEW PERSPECTIVESThc autlr<tls anrl R:rtrrt'r r:t lrl(59; Irarr obserlt'tl :r ( ()nsisl(.nl in-tlaor:rl malker- irr corrclitiorrs ol ct,ni-cal musclc sJ)asni, l'lic:ial 1lrin, :rnrlhreaclar:hes: rnigraint', tcllsior), Jl()sr-t;raumatic, chronir: claill, arrcl c:lustcr..f'he n'rarker consists ol tcnclcrncss tc>p,alpation of thc scc()nd arrcl tlrir-clnrolar periapical arcas (Fieurc 2A) ,ien il' thc teeth arc rnissing; tlie sc-JOSP'f .Volume 24. NrrrnberI. October 19!)(rrt'r'itr' :rrrrl loctrtion (lt'lt :Lrrrl.ror- t iglrtsitlc) ol tltt' tt'rrrlt'r'rrt.ss is clost,lv rt-l.tttrl l, lltt :tr' rilr:urrl l,rrt.r.rlilr,rltltc ct'r., ii'ltl nrrrsclt' sl):rsll.Stcrilt-r rrt'rrr'ogcrr ic ir r lllrnr nlrti r :,nirr thc rrrt:rrirrgt's lius lx't'rr nirlclt r.r'r.,ogrrizt:rl :rs tlr(' nl:rill r'liologit' lirt.tor.irr rrrigluint' lrcrLcluclrt' (ir l). Arr rrrr-knou'n tliguct' ( :tus('s nrt,rrirtgt'ltllrt:r'ivlrst'rrllrr trir.r'rrrirurl ilx()ns [() r('.Ir':rst' r':rsoltctivt' rrt'rrr-o1tr'lrtirlt's srrt.lrlrs lrista rrrirrt'. ltr urlvkirr i rr, 1tr-<tstatll;,rtr-<lirrs, lcrrkotlit'rrt.s, lurrl sulrsl:rnr.t' I,(21 ). 1'lrcst, r. lr<,rrriculs ur'(' irss()(.ialc(lrlith lot lrl vusorlilltt:rtiorr, irrcr r:asc<llrloorl Ilou', r'aist'cl lrvclr-ostati(. [)r.(]s-srrlt' in tlrt rrric'r'ocircrrlltiorr, irr-< r-t'ast'rl caPilluli Pr:r-rrrcalrilitr'. arrrllrl:rsniu t'xtr-ur':rs;rtiorr (5-1,7t).'l-hccclcrna rcsLrltirre Ii'orn tlrt: ltlasrna t:r-tl'avasatl<trt ('xct ts l)fcssul (' ()lt solts()r\n( r\(' ('rrrlirrgs t7l t. tr:ttrsrrrrllirrrl rro-cic cptir',u inlirrrlLntiorr lrv rrrrrntt'li-rr:tterl (. liltcls t,:r tlrt: tr-igctrrirral rtrr-clcLrs c:aurlalis, t.huluntus, lut(l scns,{)tlc()rtcx (52,54). []orlr loc:al rcnclerrrcs:;attrl incrclrsecl t<:nryter-irtul'c, pittll(),gnourorric litl irrlliirnrrilrtion (74),Iravt: ltcen consistentlv notecl in tl.,cnraxillarl rnolar periapical areiis irrct.t\t(il\Ic (.) I{ .\l l._ \ L\ }{ Iinclivicltrals rvith l:icrirl pairL (2ti) anrlrnigrair)13 an(l tensi()n lrcriilrrclrc (29).In a study o1 l,! irr<livi<hutls u'itlrchronic Iacial pain, Flit-clrn.rn (?(i)h:rs rep()rtc(l j.rrcrt,:ast:d rnii>:illlirt lh't',,1:il lt'tul,'rtr,.ss :ilt<l irr, tt,.L:t,tl tt'rrr-I)cfatrrr(: orr r[lre s\.nl])t()niati(: sidc inlir orrt o1-Jl3 praticnls and l7 orrt ol'I8 ;-ratients, resper:lrvclr'.'l ltcsc lirrcl-itrgs rvcre al:rscr-rt or rriinirrrill irr tn,o( ()lllt()l lt'()lll)s ()l- lt) ttsll)ll)l()tniili('irtciivi<luals and l[t sylnl)t()nnrtic l(.n]polorrrarrriiltrr Lar .j,.rint lrutir.' n ts ( 2l(i ) .Iti :r stu<lr, o1 ll8 itrrliriclrrals rlrrlirrerrnilatcr-:rl lclriii()n or rrrigr';rint' lrt'rrrl-:rcht:, a lright:t' ilitt'a()ral t('rnl)cl.lrtur-('arrcl gr-c:atcr- rnaxillirn, irrtr';ror':Ll tt'rr-clt'r-rrcss ()n tlrr:' svlnl)t()ntat i(' si<lc n'lrsIorrrrrl ilr ilir orrt ol'll8 strlijct'ts arr<l l.i-1orrt of il13 srrLrjcr:ts, r't'sltcctlrt'lr, (!i1)).'l'hr: 1-rlcscnct: or- alrscnct' ol .irr-trlror':rl nr:txillary lr:rr<lcl rrcss. in tlr<.Iucill p:rirr an<l rrrril:rtt'r-al lrclr<l:rc.lt<'t'xpt'r'irrrcnts rlr:sclilrc'cl alrorc rr':rsirlc'ntillcrl rrsins (lrt, {iilltxrirrs Pul.Pa-ttorr ltloct:rltrlcs.Intraoral Examination of TrigeminalV2 Site'l'o i,lir-rrrtilv tlrr.r rnirxill:rlv rrrol:rr'Jrcliupical lctr(l(:r :rrca (liiuuLrr. 2lilr,tltc t:xnrrrincr';s in<k:x flnscr- isprt:ssccl r.rltrvirrd iutd l)ack\\,arrl irs I:rr:rs possilt,k: alorrlr tltt' r'cslilnrlc Iirr-nr-itrs tht: r'ool oI tlrc < lrcck porrt:lru'lrr:n thc rn()uth is ltartiall.r' opcrrc'<1.I 1' rr cct'ss:rn' Ii rr c: I c::rrur rce, irr rlivicll r rirls:rrc lnstlucl(:cI to rnove th<' rnarrcliltl<'latc'r'allv to thc sirL.: ltc-itrg r.t>iarrrircrl(73). I'alglatirin is pcrlbrnr(:(1 li'onrthc apical :rrca ol thc rnirxil.tarr thir.rlIrtol:rr' lulrt.llrt.r tlre lootlr is l)l(.s('nlor not) Iorrvard :rs lirr zrs tlrr: crrspicllcr{iorr. tr,tl:lr i I l:rrv alr colar t cn clc'r-rr css<locs rrot rrsr.r:rlly t:xtcnd tlris 1ur- lr.rrrvalrl, but terncle rncss can l)c bcttcriapprcci:rtcd u'lrcn r:onrpart:cl rvitlr tht,acliacent nonsensitive eineiva. l'hesarne pcriirltical gir-rgival pirlpation isrel)catecl on tlre oltprosite si<lc tcriclcntifv tlresc' intra.oral "markers" l:ir.headachr:, laci,al pain, and r:cn'iclLlnrrrscle spa.srn.\
  7. Cl. INIC.\l_ (.O\t \1 1..\ t.\R.\F|GURE3.Hcl|Io*nlt:|,t|luilt'.lhrrluqhshaped k) c/o.sr'/r' ,ryrprrrrirn,r[r' lhc po-sll,lrrr rrrr.,/,rr apftr's.Cervical Muscle Flyperactivityand PainIn ulrtrost t'r'r'rl irrrlivitlrr:tl rr'itlrsignili( lult lroslt'r'iol t t'r-r'it':rl rrrrr;t lt'sJ)aslt), llrt' lrrrtlro|s Ir:rvt' rrolt'<l tlrissrrnrt''l'r'igt'rrrirral \'2 lLlvr'ollrl tt'rrrlt'r.rrt'ss. lrr lr 1irt'lirrrirrrrlr strrr[r ol irrrli-vicltutls uitlt ct'r'r'icul rntrsclt' ltr'1rt'r-ltttivitr arrtl puirr, orrt' ol tlrc urrllrolsrt:r'or'<lt'tl Ilrt' lrlt'scrrct' of l'r-igcrlirrll\'2 intlaolul tt'nrlclrrt'ss in (i2lJ ()ut ()1(i(iil cast's (1)3.1)ti,). t'r'r'rr wlrcrr tlrc:rrc2I \\,1ts t'rlt'rt tLrlr:,rrs. I"rrlt I rt'r r rtolt',thc liitcrality rtrttl tlt'tr't'r' ol tltis zorlrltenclcrrrcss :rppe:rlt'rl str'orrelv rt'latt'rlt() tllc l:rtcl'ulitv untl st'r't'r'itr' ol ccrli-cltl svrrrlrtorrrs.(llinicilrrrs \\'ll() lrr:rssug(' tllis t('lr-clcr zorrc li-t'rlrrt'rrtlv rrst lilrc llris rrurx-illan alvcolul tcrrrIt'r'rrt'ss l() lutclulpte rygoirl rnrrst'lc (irrli'r'iol Ircurl) lrr-pcractivit\' ( I 1,20,:]8). Flvcn thorLshthc Litcral ptt'rle()i.l rrirrsclc is irret-ccssibk: to palpatiorr (32,11). it t:rrrrbc asscssccl irrrlir-e ctlr'. Isonrctr-i< c orr-tr2rcrtion ol tlrc l:rtc'r-trl ptcrleoicl rrrrrs-clc, a nt:r-jor.jlur' olrcrrin{ nir.rs<:lt', rr'illclicit prrirr il rttusc lc sl-xrsrrr is I)r'('scntin this Ititrscle (31-33,3(i). ln ovr.'r'1,700 pzrtic'nts cxlirrrint'rl in tlris rrlrrr-ncr lrt' ortc of tlrc arrtlrors, rro r-t la-tionship u'as oltse tlccl lrr:trr'ccrr l;,rtclalpter-vgoid rnusclc sp:rsrn :rrrrl rnlrxil-lary alveolal tcrrcl,-'ruc'ss.'fhc authors rrncl Ratncl ct :rl(59) havc rrotcd thzrt ancsthctic inicc-214tiorrs irrto tlrt' irrtr':rolul tt'rtrlr.'r- arclroItt'rr It'nr1tolulilr r'<'lit'r'r' r'r'r-r'it ulsvnll)t()nls ltrrtl irtt lr':rst' r't'nittili lltrtgcol rtrotiorr. i\'lolt' r'r't crrtlr'. orr,r.: ol tlrc:trrtlror-s r]()t('(l tllut lclit'f lrppr:a.rt'rI t<trrrlt rlilccLli uitlr tlrc urrrr)utrt ()l ('l)i-ttr'yrlrlirrc irr tlrt' lrrt'stlrc'tic solrrtrr>rr.l'.1rirrt';rlrlirrt' is tt pott rrt \'lrrr()( ()n-str-it'1or'. 'l lris irrjt'< tiorr lt'rirrt t,s vasotii-llttlttiorr. srrggcsting :r lt'r'c'r'slrl of lot'lr,lllttliolrltvs,ioloel lrr-orrrrrl :r rruLirr st'r'r-s()rt (nlr.xillar\') llcr'\'(' rritlr sirgrriliciirrtt t'rlicltl corrrrt't tions (r'irIt' srrllrlr).'I'lrc :rrrt'stlrctic is ulso u \a 1 block-ittg agt'rrt tllltt rc(lu('('s ot' t'lirrrinute storrrlrrc:tiori in tlrt' llrirrrrt'r- llrirL libcr':;(.11) ),,\<:t olrlirrul\', 1u) ul)l)irrtrtus(( irr'otr'or r ) \vlrs (l(,\'(.1()l)crl br l.-riccl-Irran (213) spccilicullv to <:hill tlrt'rrlrxillarl alvcollrr tt'rrrlt'r- art'iL itr 1la-tir:nts srrllclirrg li'orrr ccrlical ltrusclclr'pcractivitr' uncl rrt'r'k l)lrill, \vitll ()r-rr'nthorrt lir'arlat:ht'. 1'lr(' e()al ol thisrlt:r'it c wlr:i [() r-csolvt' crlcrna ll, r'ccluc-inu local vasoclilatiitiorr ll, nor-r:irrr':r-slle lllcilns.-fht' rlcvii:t' cortsists oI a lrr:,lloxtrt't;,tl ttrlr,.' shapc<1 to lit ovcl tlrc alr-1l'opriatt' rrraxillun ll('n(' s('( l-r()nrv.[rilt' aroicline c()ntact u'ith tlit' tccth.Ilr an ellirt to rrrairrtairr Irveicrrrc luiclt'onrlolt, this nrctal tLrltc' is ( ovcr-cd l)\'lu cli:rposlblt' plastic shcutlr. 'l'lrr,' liol-lcxr' nrctal trrbe is c()nncctccl tci an ic<r\\'rter sour-ce ltr' :t snrallcI gatrge |lrlt-trcr- trrlrc.'l'he ir:c \\'atcr, (1li\.('r) l)\ a\ltlall l)llttll). pirss( s tlrrorrglr .ll(lcliills ther ntetal trrtrc.'l-lrc colrl r,,utcr.the'n Ilolvs ()ut ()f the rrrctzrl lrrlrt' lintltlrloueh tht-' rrrlrbcr tubinc, ,,\'lriclrconnc(:ts to ltrr irk:nli.cal arr:rnQcrri,.'rr1ol trrbe s on thc o1>pt:,site siclt' o[' tlicrr)outh; the connectinr4 trrbirre is longenottgh {irr thc brrlk o1 it to lrt'orrt-sicle the rnorrth (Figurr:3). Finalll ,altr-'r' clrilling the nre lal tuitc on tlr<rothcr sid.e ()l tlle nrorrlh, thc' u'atr.r' isrt'trrrncrC to its sorrr-t r'. Irr ltrr-'lirrrirltr-r,obscrvatriorrs oI rrnillrtr'r'al trL,utIn('n1ol irr<livirluirls rvith rrrril:rtcnLl lrt'ircl-a<:hc', lh C intra()rirl tInc1<'rnr'ss urrrlIte:rrlar:lrc cic:casionallv slrifit'rl to tlrt'oplposite sirl<'. r\s ir l'(:sult ol this r-r:-sl)()lls(' rt() ur)illrt('r2rl lr-t'2rtnlCnt, t :'(at-ul('llts art' rrsrurllt' l)('t lolln('(l l:,illrtcr-allt,. FiLrurt' 4 illrrstrlrlcs lrciltnt('r't..Arr cxltcrinrclrI w2rs utl([(]rI :rl.('ltlrv tlrt' irrlrth()rs to scc il- llcatnl('r)l ()l'tlrc lrrlr-aolul 1t'rrrlcrrcss u'oulrl ltavclttt cllt'tt ()n s\n)l)t()rrr:;. 'l'lris tcrrrlcr.n('lis \\'iui c\':rlrr:it('(l rrsirrg tlr,.r ltlcvi-otr;ly <lt's<'r-ibcrl 1xrl1latiorr 1rr'or t'<lrrr-t'.A nottblitrclcrl lrilot strr(h \\,;,ls [)('1.Iirr-rrrccl orr l2 srrbjt:t'1s rvitlr clirrir'allvrlctcrrrrirrcrl ,:cn'ic al rnrrst lc Ir1,1tt'r'irc-tivit\'. ALI ()l thc subjt:cts irr tlrc st rr<lvrt:porti-'rC lurving ncck. I)lrin iit lcsit lul(l<lrrlirte r)lovcnrcllt ol tlrc r:cn'ir:alspine ; irttraoral tcnclcrncss r\'trs Irl-cs-('llll rn :tll sulrjt:cts. SLrll:rcr: ('1.('ctr'()-llr\,()g|apllic actiVit)' r.r1' thc trPyrt'r t|a-pc:rius, and Pxrirabl)r ol'llrc lLclul()r'sc:apttlac as wcll, w:ls li-'c()r(l('rl lrr'Iirr-canrl aficr tr(:utrncl)t witll thc (lrrrrtron<1c,,'ict'. I'hc Patlrn'ar,,/'lvlR 20 (Polta-blc lorrr.channcl r:lcctr-<tntr'oqr':rlthicrrnit) (I)r-ortrctircus ()rllrrp, ['orts-rrroutlr, NH) u'as usc,il t() rccorcl thcavt:r'nscd (lcft ar-rcl riultt siclcs) irrtc-gr:ltr:rcl clLectr-orrt1'oeruprlrir iictivit,; ol'tltt' sclcctr:cl nlusclcs (16). Irollou'inel5 nrirrutes of trcittnrcnt rl'irlt llrr(in;otrorL rlcvi<.c, nirlc ()lrt r:,1 19 srrl>jccts cienionstratcrl a lcrluc:t,ion in tlicclc<:Lrornyouraprhic a(tivit)' ol' tlre. se-lectr:rl rntrscles lts cornJrarercl rvith prc-tre2rtrnent lr:r'els ('falilc l). In tlrt:sr:satn,: nirte inclividLrals, therr: u':rs arnc:rn ittcreAse of 10.:i8 + tr.95," o1'tnOtior-r in the single nl()st [)ainfill'folurne 24 . Nurnber 4 . Octobcr 1996 .'.iOSPT
  8. ( ('rli(':ll sl)in(' lll( )\'('ltl('l) I 1i )l l( )\r i ll gt|clltnl('lll rvitlr tlrt' (,t-r'()tt olt. I:ttt tltt'tinvt'stiglttiott lt'r't':tlt'<l llt:tl tltt'(lr\,()tl()rl ltlso a1l1tt'ltl's lo tt'tItt< t' ol'clitttitlttt' t t'r'r'itltl 1t:titt ltrttl Ittigt:tilttan(l t('r)si()rt Itt'ltt[:tt ltt'. .'\ll o{ tlrt'oriqirral 1 2 srrlrjt'cts rlt'scrilrr',.1 tt'stittgct'r-riclrl pairr. urt<l six of tltt'st' irtclivirl-rurls rlt'st lilrt'rl lrt'lrtllrt lrt' rts tr't'll; trr<rt,l llrt'sc irr<livi<lrr:rls' svrtll)t()lttri llt tlrt'1rr t r i,,ttrli rlt ., I ilrt tl Iltitlt;tit t t t il, -rilr, irrttl firrrl a1tlrt'urt'rl to lrt tt'ltsiott-FICURt 4. ir,rlit,nl bcirrg lrr,,rl0r/ /rl/.tlIr,r//r Ir rrt/rir c nt,t.rt//.trt nt'rtt' :Jtslrtbultor) .lIr',1 t'(/(Yrr(l( l.ll\l(..\l(:()\1 \llL.\'l'\R\tvpc llcadachc. Itttrltt.,t'lrl (.t-rc'tlorrtfc:ltlncrlt (Ji lir-rtti|rlrtcs cltlIltltt,lL t-t'-rlut:e rl ,ll elinrinilte<l ne ck 1:,uirt rlteir4lit orLt ol' l2 irrrliri,ltrals. lrotlr nri-glairrt's, an(l t\\'() ()u1. :)1 tht' lirrr:' te tr-siorL hr'a<lacht's ( I'lil.rlt' 2).Irt a sirrgit' casc slllcl\'. ottt' :;tiltjc'ct\\'irs trcate(l bilatc'r'alJ1 uith tht'( lrlotr on rr'lrilc srrfli r-iris Ii ont :igrrili-cant tLltlisioll lr<:atlltc.ht', ce lf ic:ll l)aill.:rlrl r-t'strictiorr o1 larlt'r'al c,-'rli< lrl fle r-ion atr<[ lirrrr,urcl (]crvi clrl flcxiotr.Ilotlr o[' tlrcst: rnovcrn('r)ls cli('it('(l ilt-( l-('lls('(l ul)l)c'l' tt ltllr.:zitts Plrirt lril:rtt'l -all[r'. Irrtr:gr ate <i srrr(rLt't' t'lt't tt-oI rt', o-glapllr (toot ttte:ttt stlrrltt't') irr il\'.s('( ()n(l! r't.r'c:rlt,ci a\'('l-:r{.1(' r.lt'l t :rrrrlliq-lrt sirlcs) rrtlttt's of 178 p\'olts "st'<'billrtcllllr' <ltu-ing Iirr.,r'lrrrl l'lcxiorr antl5itir g.\I,rlts,rs('( c()nl.r-irlatcr-itll\ l() lat-t'rltl llr'xiort to t:;tt:h siclt:. lrr tltis cltst',('l( { lr()nt\'()Sr.rlrlrit rrrollll( r ittq rr:tsrrst'cl r,ritlr t i'r'r'rcltl ni()ti()rl, rrrrlikt' tlrt'pilot sttrcll irr rvhich t'lt't tr'otttvoel-lt-lrlrl rvil:r 1rt'r'lirr-rrrt'<l otr (ltt' Itllls(ttllt-ttn-(: lrt l'('st. ,\[t(:r' ()rlL\' 3 lllillttt('s ()l'( lrl otr,lrtt t l-(:.ttrlrclrt, lrelicl:rt'lrt' I't'lit'f\\';,rs r'(:l)()r'l('(1. ,\lit:r a t()tal ol I l> rrrilr-trl.t's o1 c()lltilnt()tts ( ltlott'ott tt't'ltt-rr.r'nt, Itc<'k patrr lra,:l also tlislrl r-1r,.:ar-r'rl, a( con)[)iuri("cl llV irtcr t'itsccl('cl-\'i( irl t'attqc ol IttoLi()lt, as lc{'()l-(l('(ll),r' twor:liln('n si()llal At-ic I <:oIt rpr.r t t' r'viclcotrupltr'. 'I'he it'rt r-eitst' itt ccrvit'alrlrrrgt' ol' Irr()li()rl ttot,.'<l allt'r' (l:-\()tl ()llIr (':rtrl(:r] 1 r t:rlrrit'ctL lr() a(l,Citi()lllILrlrtis('lc Iirttc. lts t:r'irlt'tlct'tl lx ttrl litl-t lr t'r- ir r,::r'r::rst: irt el<'c l lot tr\'()gr':I[) l ric<lisclr:rr-gt' li'otrr t:ctliclrl Irrrrs<:lt's (37).l'rolractccI b<:rrellts, ]:rrair]lcIl:IIl( (: ()l< r.rnIinuous irrclt:asct<l PililllLcss ( (]llicalfrin{r(: ()f lnoli()n, \\'(,'rc r(]l)r:)rtctl 2-1Irorrls latcr'.\\tlrt:rr rttck pain is acc()rtrl)11Ili('clbv rr t'rr r-oloqic al involvetlt:tr t t't'sttl ti It girr trpp,l:r (:xl. r(:lnit\' \,,'caknc ss 2irltlrrirrs<:1,.r atx)l)lr\', hr'p,:rcstlrcsi:i, altd<lvst:st bcsi:r, thcrc irppe:rt-. to bc :tr,:r<ltrcccl cl'lbclivencss o1' Ittaxil.atlrrr:nr: ( )ryotron thellrpr'. IIrtr':r<,t al te tt-clcrrrr,'ss is prcscnt, but, tlt lnir.lrv cas-t's, rrt-:i1her irrtraora.l tcncl:rncss rl()l's,ilnl)trinl: t cs,rlt<'. ,.'\ (^t) al l('l ( \-tr:rrtlt',ri tre:il-rnclI[ (]t uP t() 4ir n-rttt-ulcs. Irr all pilot stl.(l\'po'iitivc rt'-Precryotron[-R Average['ostcryotron3-MinuteResting[-R Average_15-MinuteTreatmentROM ChangeDirectionDr:grreesBLDECuIIKL138.366.5104.5510.7514.89.442.464.2523,110.759.95'17 .142.6542.6824.158.043.851 t.B56.541.628.2i 1.551 1,856.48.217.3213.79+11;+21+21No change+5+6No changeilr)+11No change+11+1910.586.95LLFRROLLFLROLRORROLLFRLFRROLLFRROLROxSDRRO = Right ( crvi..li f()t,lr/()/r.IRO - lctt r ervit,t/ rol.tliotr.RIF = Rrght hlera/ cervlt-r/ tk'rrr-rrr.LLF = I.eit hrer;/ cervt,r/ t/erron.L'RAvcrage,=l1r,erl8t,e./t,c|rr,,rllr'rlgr.r1l/tlr.rttirrt1ip\,tbt,lttt,t,ttIevatot Scapula.ROM =, Range oi mot,rtrt.TABTE 1. /ntegrated suriace e/tt frorttltryr.tphirand the mosl painiul cert tc,tl ntotiort, cert';calaclivitv tg\/l oi uoper tra;tezius and levator sc;rpu/,1 ntusr /esrotattan, ()r later,tl ilt'.tion ln patlents r|rfh necl [)atn lN'r '= 1)lIOSPT . \blLrrnt: 2'1 . \urtbt'r'-1 . Octolrtl l!)9ii275
  9. (]t-INI(],\Ic()\l \1 t..\ I \R\Pretreatmenl10 Minutes PosttreatmentHNPCROMNPCROMA2BOC3DOE(]F(]\JlH2l0)1K{)L1)22I)I222I23001000200I00211I0020Il0iiLLF)IRRO)ILLF)ILRO)ILRO)IRRO):LIF)IRLF)r RRO)'LLF),'RRO)iLRO)0 .. No p,rin.l .- Nlild ptrn2 .- Moderatt'p,tin..J -. -5ci,erc p.rin.LLf - Lell hk,r.,r/ r'r,ryir,r/ /ii,irrrrrR/ F - Rqqht i,rler,r/ r'r,rr lc,r/ t/t'i,rit.I RO lt'/i r t,rt rr i rolatton.RRO - Riqht ctnrL,tl rttt,ttr tnTABLE 2. P,ilienls'hc,rdrr /rt, (t|), rt'stinq rrt,r I p,iut,ltter I.i ninulo\ 0l ( rt?lrorr l/r,.rlnti,/ll.sl)()r(l('l s 1() tr'('lrtlll('l] l. i rr I Ilto|itltt'rtrlt'r'rrt'ss rvlrs citlrt'r' t'linrirlrlt'rl or('()nsi(l('r'al)ll lt'rltrct'r1. 1'lrrrs. tlrt' lirrrlittq ,,l ll( nrr)l(,,gi,:rl irrrl,,rir rrr, rrl rrriti-gat('s lrqlrinst rrsr' of ( ltt()lr1)ll tltt'r'lr1tVIir Ircck puirr ltrrrl nrrrst lt' sl)irslll.(lorrvr:r-sclt', tlrt' plril lrrrrl lirrrillliorrol rttotiorr tlltl :tct orrrlnrn t t'r'r'it lrllltrttincctorrn (lrrrtt'r-itil lrpplotrt lrl.n'itlr ol u,itlrotrt st:rlrilizlrtiorr, Irlrslrt't'rt lirrrrrrl t orrsistt'rrtlr lcslrorrsirt' lo(llt'()tr()lr tlrt'r'lrPr' ( i\it.lsolr ).DISCUSSIONA 1rt'r'sistt'rr t irr t nrollrl t(,1)(l('r-n('s:iirr llrt: l't'igcrrrirrul Vl2 rrt'r-rt' rlistlilrrr-liorr ar-r::r ul)l)('als to lrt' irrlr>lvt'tl itrtlrt: rrrctli:rtiorr oI r't'r-r'itltl rrrrrs<']t'sl)llsnr. -l'lrc |t:srrlts 0l tltr. 1r|t'st'rrt 1ri-l()t sttl(lv sugq( st tlurt ( irr'otr'ol1 tll('l -aJ)\' t() tltis lrlc;r rrr:rv lrt' t'llt.< tirt' Iirr'tlcatilrg tlrc lirnitirtiorr o1 rrroliorr irrrrlpain :rss()ci2rtt'rl rr'itlr c('rli( ltl rrrrrst lr.'sPasnr.Stcr-ilc ttt:ttrogct rit: irrll:1rrlrati9rrrvith plasrna cxtrlrvlis:rti()n (crlcrrr:r)ltas li'c<lrrerttlv lrt'crr clescr-ilrctl its lr,-'-ine respousil>lc lor vascrrllrr- ht'a<1-aches (54) ancl lacial Irairr (2(i.il0)Horvever', a lclatiorrship bctut'crr rr,.'rr-27(rt\l)r. ,tnc/ tertittl ntolton ((ROt\l) pain r,tllng l)t:'torr )ndA relationship betwe'e'nneuroSenrcinflammation andcervical musclehyperarctivity and pa:inh;ts not beenprevilusly desuibed,,t ogcrric irrll:lnrrratioll lut(l c('11 i,:talrtrrrsr-'lt' Iultcnrctivin lrrr<l ltairr Ilrs rrotlrt'<'rr 1;,r-t'r'iorrsll rlt'scriltcrl.'flit' ar.r-tlrols Iotrncl tlurt lat.cr'.rlin' arrcl scr,t'r-it\' ()l intla()r lrl tr:rrck:r'rrt,ss irpJr,.,tLr-r,r1Io I t'llitc lo ccrliclrl st'rnlttorns (,,'ir:lt'sttPl lt) , :trttl tlrat intllrot:rl aPlrlir arionol tol<1. r-cclrrr:t'cl or clirninatt'rl tlrr:st.ct'rlic al :jvtn J)t()rns.t. iltillirrg o{ cclcnlrtorrs rrr:r>:illlrrvtrt rrr' tlislt ilrtrliorr art':rs rlt'r lr':rsr-.-.t:xc cssivc intrracapillar-\' l)r'csslrrt.c:iIus,ir(l ltv pl;rsrrr:r cxtl avttsati()n ,issoci-att'rl rr,i th vasoclilirtat.ion (58), ther'<,,brcrrCr;,trr aging e xccssive inte rstiti.alIltrirl (t:dcnru) to rctrrr-rr to tl)c lr-liLcl-o-crlcrrltrtiorr via tLrt' caltillan rv,all (72).'I'lrt' irrtt':r,rt'trl tt'rrclcr-rr,:,s:i irl)l),..llr-s l.(.-lulccl to t.'clc'nta. ('\('r'tilig l)l-(,ssur.(, ()lls('ns()l'\ trc'rlc r.nrlings r,ii{1.'l'}rt. l:rcttllrt tlrt' l)il()t stlrdv pltrccrlrrlt' :rl{irlrlcrtr signiiicunr srrnpt,:rrnatic r.t'l t'f'su{g(':its thr' 1r<>ssiltilitv ol a lt('r.lr-()-gt'rric irr{litrrrnLrlir.rrr at t.lrc trclrtnl('nts it r'.( .t'rr ir'lrl nrrrst lt' lrr'1 rcr':rr lir itr rrr;rrlrt' r't'sponsiltlt' Ir>r tlris loc:rl stt'r'ilcirrflanrrrlrtion, rrlriclr st,ncls nocic.t,1r-tivt' inrllrrlscs to tlle r cn'i<'al iu ('il. I)('n:l)('tllalillg ntrrsClt' s1>asrIr arrrl 1),iirr.-l'lris "r'icioLrs r:r'r'lr"' ol' nrrrs<'lr' :il)lsrnl)('r'Ir('lrrati()n is sirnillrr- t() tllul ()( ('rrr-tirtg r,tltt'rr :r rrrtrsr'lt'irr srtitltirrt'<1. i,lrIr-action cr'( lIt('s rrocit clttir,'t' sitlrslltrrr t's(isr lrcrrri:r l:.rctic ircirl, srrlrstlrrrct, I'. r'lt ).clursirrrl irrrprrlst:s to ltst'r.:rtrl r.ia slrin<'tlr:rlurrric u :l('1.s t() tlic tlralarrrrrs :rntls()r))lrtos('ns()rr |0t tc:x ( [ 2).I rr I llrrillrl t r1'ol lrclulti :tl)l)('lu s I o,lrlli'<'t rlrt' sntall. rrrrrrn'c'linlt('(l t:l 1ilit'r's rt'slrr,rrsilrlt' lirr rlt.<:1.r rrrrr:;r'rrllrr'lltirt llrllrt'r' llrlrrr tlrt' ltrlr;cl' A l)t'lt:rlilrt'r':i lt'sJronsilllt' f irl sllrr-1tcr'. rrror t':urtrl,'tr lxrirr. Irr tlrrt.t. 1rr)\ill\(. r('-slrorrrlt'r's t.o (lrvotr'orr tlr:r':r1tr', ltlior'(lrr'ollr )l) l.r('lltll('nt clirl tro( arrrt'lio-llrtr' plrirr ,:'lit:it<'tl lrv alrltlit:ution ol't'lt't'tr-ir-' ( u.r'l-(:nt to tlrc lallial surl:tc.t'sol llrr.' tr1t1t,,rl irrcrsr.lls ol rnitsst:lcLir.tliggt:r- ltoirrt rlrt' rrcc<lling.'IIr<'st' rt'-srrlls lrlt' r:r:,rrsislcrrl tvitii,otlrcr {lrrrlirrgs <k:rrrr,rrstrlrtirrg <lrrr irl inllirrnrrur-liorr irr t'xltclinrr:rrtal irrrirrrals, ltrrt rrotirr tlrost' irr rvlrorrr (l-llltr.rrs w'crr. lrlt'r'i-rirrs rlcstr ovr'<l (52).'['lris w'ork rn.rv lrc siqrrific:rrrt: iti<lt'rrtifit:s r.rrr intrlorlrl rn:rlkr:r firr c.t'r-viclrl rnrrsclc sl):tsnl, rclltt('s lr nL'rrr()-ut'ni, irrllltrnrrurlion lt) Il itl(.rllilto{ (.1-vical P:.ttlrolthvsirtloqv nssociatr:rl u'itlrct'n'i<:ul rnusclc lrvpcla< tivitr', uncl sug-e('sts a rtcrr rrottirtr,:tsirt llclrlrrrcnt li,t-ccrlit'lrl rritrst'lc slxrstrr iincl ass,o<:iatctlItcuclat lrr'.R.irn<lr,nrizccl ;tlacc:lro < ontr ollc:lIongitrtrlinal strr(lics art.' r'c:11uir-cd to< onlil-rn tlr arrthors' clrnical inrpr.cs-siorr thal t'lirtrirratiorr ol r'dcrrna at theintlaoral l-r'igt:rninal V2 ncrvc ;lrcubcrrclits 1x-'ople rvith ct:r-r'ical rrrusclcrh1'1>cractivit.r' :tn<l lclatcrl lrcacl arrcl\irhrnrc 24 . Nrrnrber' ,1 . Ocrrbel 191){j . JOSITf
  10. rleck Paill. ()lltitlir.rn-r lcngtlr ol tt-t'llt-rnt:ttt Ltrtttttitls ttl llt' clett't'tttillt'rl ltsu'cll.SUMMARY-l-he airlr of this l)itl)('r \\'lls t() Ir''-vicu' thc cotlrlitiotrs cotrtttlolilv t-t'-sporrsiltlc lirl hcacl :ltlrl trcc'k pltttt'Adrlitionallr', sittct' pclsistt'Itt 1t'Itrlt't'c(1cI'ttlltotls ilr('ils w('rc lttltctl itttt'lt-oralh' itr irrclivicluals nitli rtt'tk prrirr'att c'clt:trt:t-tctlucirtg (rtl()tll('t'lll)\ t('( ll-rritlttc u'as t:rtllllovc<l to sct' il t'rlt'ltlltrcsoltrtion u'ortld al li'ct tlris c'otttli-ti,rrr. I'ilt't sltt(l\ lt srtlls sllgll( sl il lrori-tivc cllitct ott llostt:lr'iol- ct'tlit:tl t'lt'<-tt otrt-voQt alllric at'tivitr', t t'tlit al t aItgt'ol ttto(iott, rtt'ck llairr' :rrr<1, il l)l('sclll'..associatctl lrt'ixlaclr':'. l( )sl'l'ACKNOWLEDGMENTS'fltc litttltol-s u'ottltl likt' to ltt-krron'lt:<lgc tltt' tottttilrttliotts oI.f oscplr Wcislrcr-u, I'lrl)' I'-l ' l)t'rrtt'l'rtoto (lollt'L{t' Ilcllltlr Sc'it'rtt t' ( 't'tt-tcr', I)ix I Iills, N\" rtrr(l l]('r'1r'1tr)r[ '\gtts'N{D, (llinical Ass<it iatt' I'r'oli'ssot ' Nt'lVrrk Univcrsitv Sclnool ol \'lt'<lit rrrt"t.vcn'\irrk, N\'.7. [:ilttesktrtc R: Rhertnl.tto icl artt'ritic ltt:IilLrr,'.slont' R fe./), Rht'untalolop"t, ,ttp 3'1, I )9 -l"tt l . Bostrtrt: Hrtttp,htort 'Vi/i/t'rrllr)/c.s.siorr:l/ P ubl i shc rs, 1 9 B t)U. Bth,tn ,'\, Pt'ter J: Polvntvositis 'trtri cler-rn.rtotrtvor;llls. N Ingi I l\4ed )')2: ]11i19, 197',;9. Br(\\'t) \\,'r, Bttltttt't ('F: (linical i:-lr.-ttrttrt'tvog,r;tpi ;\', 1tp 126 1)B Lonttttn [Jtttt'c r\.\'o ft h - 11 c i n ent,t rt r t, | 9 B 7|0. Sulbul R, f{ril/larrr.s f4/\,1 -schtrrlacire'rt 1fl., Jr: ['sttri,tttr' ;trthrttis [)iv'ersr' 'tnri,,,,tl.11l,rrr'., hrg,hIy' clestrttttiye f'osl,gr'trii\1(,d 97t-L):()7-99, 1 -l 106, l)tt, I q95I L Bttrclt J(i: ()t'r'lttsirtrt relitted to l;tcialo,tirt. lnt. Alline CC lll, Mah;tn l'E @dst'F,tti,'tl ['airt ()nd E(l), pp 170, :,11 |'hil-artelplti,t: le.r Ji Febig,er, | ()77t). (.aiIIit\ li': P,tirt: lVlech'trli-snl-s 'trtr/ '\1'ltr-.Ut'/1)€'/)t, pp 3-5. Pltilaclell;hi;t: f A'/),tvis Con'rPa nY, 199 )I i. ('rtht'n lt1J, Ntu'Artlrttr L)L: (-la:sitit 'ttittttrtt rtti,qratrtr' ,tnc! lcrtsion ltt..acl'x l'tc tnnt,r .st/r\('\' ti 10,000 he'ld'lr'/ t: tliarit's'/ /c',rt/,rc'lrt' ) | :)5 2(), l9BI/-1. ('trrttntlrr,g WJ, SaLtndt'rs M hlarlit'ttIt.,ltatltv' .ls .r c'ontp/it',tticstt ttt art(t'/r-'s-ir,lr. ;lt,,rtdt'liti-s. / Nc'trro/ rle'trtt'rstitg/,,r,r.hi,rtr1, Jl(6):5(,() .570, It)78/.5. ( r'rirr l: lt'xdxxtk of ()rtlt<'t1t'terltt,\1t'rlic irlc'. I)irgno-srs r>i Soli Il'ssrri' lt'sitrrrs (i'fh Icil, pp tJ7-g0, gtl Ltttttlott:Iltill tt'rr.' I trtctall, I ()71)| 6. I)t' t tt< t (.J: List' rti the' stirr'rr-t' fful('st,t,nal ntr pcrl'orntat)ce ev';ltti'tlittrt ttll;,,rt'k rrrtr.sc h-s r\1u.sc /e Nt'rt'r: 16:) I0;'16, I t'()-Jl7Ihtclnteatls J: Heatlaclte ,tnd he'ttl 1t'ttrt.rs-soc l.i,r,r/ rvllh r/isease.s oF th,.r ,:.{'rvi('J/sltirte. lilt'cl (lin Nttrth Ant (t2(l):5 1);;11. l'l'tiladelphi;t: W''B' Saunr/crst,tnt1t,tttt. lt)78l:kbrrrrr K: Sonle'oll-servation' tttt pJtn ttlr /ti-sler /tc'arhcht-. Heaclac.ht' I J:21(),12.5, | 97.51lt. 'lnF,el iVC, Ri<'hrttond JIJ, llrotlit' AL:,\4,tnclilrular p,row'th dlstu''l'a,'rrcr-s irtrhettmat<tid arthritis cti <:hilChc:ocl Ant IDis dttld 7B:7)B 71'1, l9'll'))0. [:vers;trtl C: A14'tliecl kirte;iokry,',' ln:.Cclb t1 (ed), (lini('al M'tnaqerttertt t';li1errl, Neck ancl TMJ P'tin and L)ys'fLtn(ti,:.)n, pp 1B()-505' Philadelphia:l\r.ts. !),tunders LontPitnY, I l) 7' 7)l. [:;tr.tci FM, Kadel KA, Heistul /]1): V'r'strtlar responses of dura rq'ttr::r' Artt JPhysit,l 257 :H11 57-l 61, 1 )"J91)). Faucltalcl P, Ryp,vold O, ()y'stestt l):Tt'rtt1:Ltr,tl arleritis artd ptlt'nty'a.lg'ii.trhr:ttnt;tlic;t: (ltnrc'ttl and ltioltsy' tincl-ings. Ann lnterrt Med )')':tJ|5-851,1 977'' 1. l-einntart C, flarris M, Ca"vley R: Psy-c h o gt' r't t c f a c i a I p a i n : [' r e s t: rt t'.t t i o rt a rt d(.1.1\l(. \lC()\1 \ll.\l I \lLY).1)5lh)7trc.,rtnrerll. Ur Mecl t )ll8:1 .:16 I lti,t 9[i1Frt":lril<;t:r't t,4, llot'tlal 11, 5 jaa>t,tcl ('):(,e'rr"rc r4;e'rrit 1t,,'.1/;11 lre: Clirt';< ,tl ntarr-tiestatit,,n. Cepl'talalg,r.t't.l 1)'- I 60, 1 )87L r ietl rt't,t rt Alt' : (' l),1 | ac t'?t i-sli(--s rr/ lt"/l:'tott/rr'.rrlrc lre': ,'\ prriilt' oi 1 1)0 ( 'lses Dsl'-clro.sont,tllt.s,l().15 l'lb1, I ();''')F r i t:c! rn ;' n /tl I 1 :,'\ty 1t i t ;r I i al a I pt't i rt : l' I t er'r.rrtsl-sle trr 1',:t'i i 1 n i I att'r a I rtr'lxi//ilf v lrc'l1t'r c/c'ritt'.s.s a/l(/ e ft'\'.1ll( / t('tl:,pt-'r'1tL)r(' l,jrrrr IJt'itt.ti ,lssoc /2t'r:,9.5.5 ti60, |955l'rittlntart A4l 1: 7t'ttrtrtt,t'oslll-'; o/' th€'rtt.l-s.sel{'r tttt.ts< /t': Rt'i,t':rrl r-tl (''l'se'5 / l\r})[)t'rrl.t/ Assor' | | 0()) .,1..01 2 20) t 9tJ5['rittlrrt;'rt A'1t]. t/.-5. I';rli'ttl # ';,5)7,'151f [,tA (.l,'.'.trarr<r'. Jttnt']0, l':)()6l(). I-r"t'rlnt.trt Nllt, I ttrltt,-'r\F: lltsilateral rn'tr;.t-rtrtl lctti/r'tttesr .t'tr/ t'/et"tl'c'r/ le'nl-l)('r,r ltr r(' t I tt r i t t,r: t t rt i l't tt' r a I tt t i e, r't'; ttc a n dit,,'rrron-lv1x' /tt'.lrllt itt'. t- (lnclL'rl t'vit'Yu'/.i0. 'r'rit'rlrrt,trt Nll l, \A/eirttrault /Y11, I-rt'rtt;tn.9; ,Atyl;ir'.r/ /.rt l.r/ lt,titt: A loc;tlizedrtt,trr//,t11' t1('r\'c dtsotder/'\nt | ["tirtA'l.r/).r!t' 1: t'l(.) 1 5), | ()l)liI I I rttrlttratt A1/ /, \4t'is/rr'r I l: t\ltltlita'tLtrto" ttrtl,oltcclit prit)( iplcs ltt t'v'l/rr'tllottot Ilrt lt'rrtltttrttrtt,trttltbttlar jttirtl l'hysIltxr 6):597 (t0.), | ()l'i)i,l. l'rittl'n.trt ,Vl l, \\/t'i;ltt'r'i' J: Pitl''1115 olttrtisr /i' lt.tllt,tliort in TMJ r/i'l,qrtr'rst-s'J ['rtt:;tht'l t)t'ttt 1tJ:)']l, l9ll'li l. I rir.t:!ntart Nll !, \Mt'isl'tt'r1i J: S< rct'"'ttrt13llrrrrtr'/tir<':; l'or l'::ttt1t<'ront't'.tclilt.tularjrtirtt,:ly'sitrnctittrt ilrrrt I-ant Physici'trt;'5 157 1(t('t, l9B2I5I rictlrnan N4l l, Wt:tsbcrg J: letttltor<ttn,tndil)Ltl,1r J(.tinl L)t:,ttrtltrs, 1tp I i, '\6ql, t0l 1()6. ( ltit a,qtt; Qirinlt'ss':'nrt'I'ttI.Ii.;hirtg, ( rtrt't1tatty, Irtt", i' ()'95l'rtt:(lnt,trt N1t !, \\/t'i:;l>t'r'g J, r\g'us B: Di-,rgnrr:;ls :tIt(/ rr(';lt/I/('rIt tti in1'Iarttttt'ltitltt,Ji tl'tt' tetrt1toront;tn':ltbuIitr ioint Sentin,\rlhrtis Rht:utn I ):11-lil, 198'',Fricdnt,tn h4t t, \Mei:$erg /, z\gu-s IJ: Nc'-.e, l t, c tr : c l ( ( t rt t I i t i o t t s ( a uslng pt r e a t' r i c u l't r'trtrl reft:rred pain. 'l Neuro / Neur(r-sur8P\<hiatrY 4b:1067-10t'2, | 983)t)t1REFERENCTS1 . Abrahants V(', Richntottt/ F/R' Rost' /'K:Alr-senr:c ti ntonttsyrt.tltttL re[lt'x in d<tr-s.r/ neck rnusc/c'-s ol thtt r''rt lJr'rlrr /it's92:l30 131, l97t). Bertensort A: I'ht' t'ontirtttirtg, s'18'l ()lLynte clisease- t\m J Puhlit Health 79'9 10, l9B9J. Bengtsson B, /r4alntvall IJ: (]i't'"tt tallarte'ritis. Acta Aled Scrnd 6U5:l l0)'I q8:1. tlloc'k SL: Dil'ferential diap,nc'sis tttr:r,tnio facial t'ervical p'lin ln: I ltt'T e nt p o r o nt ;t n d i b u l't r J o i rt t' t\ B i o I o l' i t a IBasi's ior Clinicitl ['r;tcticr: tltlt '!:rlt, 1t1t45B-159. PhiIaclelphi't: W LJ S'ttrtdt'rsConttt;tnY, 199 )5. Blue'storte R: Ankylostrtp' sponclvlitis lrt:.- ir,inny 1;; 1e'd), Arthritis antl AllttrlConditi'ons, pp 819) Bl0 Philadt'lphiaLea & Febiger, l9B56. Bluestone R: l)egencrative joint rlis- "rr"t A c!isease o'i cartil'tge' lrt: IJlue--srone R (ed), RheLtnatolop'v, PP.61 7l ,Boston: Houghton Mifflen Prolesstttn;tlPublishr:rs, 19'90.JOSPT . \'olurne 2'1 ' Nrturber'1 ' Octobcr l9!){r17. (;ateryJ\' Ilt'ctrtxltagnr''sti('l aborato'ries, St,rtcn /.s/ancl NYIU. Cclb Il: I'atiertl €'v,i/t/.llion' ltt:6elb lt('(1), (,lini('al ,M,tttttgt,nent oi l'lead'N'c't f, .trtr/ "'r 'MJ P,:tirr ancl [)ysfunr"tittn'pp 95, l)(:. l'}ltil,t<lt'iolti't: tA/ B Saunclers(.ttn''P.tnY, 1977J9t. l lttnter (R. Maylic:lcl f H R<tle of thettltpt:r rt:rvir.al ro<is in the pro4uctiortrit' p;trn irt tlre lttt;ttl. An'" J Surg a8:74375 ,t , 19'191 0. I rt It: r n at i r ; r't,t I H e tt t! ;t t: h et S ct c i t' 4' L1 e ad;c:|te Cl,tssificatic'tt ancl cli'agnostic <:ri') ()2';i
  11. ct.tNtC..\t(.o\t\1 t..\1.\R\ten.1 tor hr',rtLrc.l;r' clisrtrrlerr. t r,;nraln e u r a I F, i,1 s,,t n ct t,t L i a | 1 t,t t r t. (' t, 1 t lt a l. t I,q i,ttl(Suppl):t(t 22, 71, 7), tguti1l. Joltnstonc t)R, 1'r'ntplt'ton tr1: lltt' tt',tsibility ot. I),tlp,1tit1F, the lateral lttt rr'y4oid nruscle. JProstltt't Dent 11:lltll)3, I 9801). Kapanclji It\: Tht'Phvsiologv til tht'Joints (Volunte .l). The Trunk ant! tlteVertebral Ccsluntn, pp )18 )l(). Lon-don: ()hurt.hill Livingstctne, | ()7111. Kt:ndall FP, M<Oreary FK: ,t1usr /r,s7'e.slirrg anct Fun<'tion (.1rd Erlt, ytlt )51))60. Il,lltinlore: lUilliants N l4/i/llrrs,t 9B.l11. Kt,rr F14/L, ()lafsson RA: Trigt'rnin,tl r t'rvical vollevs: Convt'rgencv rtn stng,lt'units in tlte sltin,tl gr.ty ,11 ('l ,tntl ('!.Arcll Nt:ttrol 5:1 7 ,t I 7lJ, I ()(t I1.i. Kreutzer KL, M,tlt,tn PI:: Tt'ntltorortt,tncliltuIar ctegcnerativt' joirtt dist'asa. [),tr II . An.tt<tnty, pathopltysiolLtgy,, ,trttlclinic,tl dex rtption. ()r,tl 5ttrg, 10:|6,| 69, I 97516. Kuclntw L: Paradoxit',rl t'flctls ot traqLrent dnalge-sic' tr.sc.. Aclv N't'urol i J:tl5 .t4t,I9B217. Kugelbarg F,: Faci,rl rr'l/r,.rcs. []rain 75:385 t96, 19521t) Kttp,t'llrcrp, F., I indl.>lont LJ : Iltt' rrtt'r'lt,tnisrtt of thc pain in trigt'ntin;tl nt't,rtlgia. I Ncurol Neurosurg Psy,chiatrv )):]6 1_i, 19591(). Lullnt,tnn tl, Mohr K, Zit'74lar A, Biagt,rD: Color Atlas ol' Phitrntatoltry,v, 1t1t191 196. Stuttgail: Thientc lr4t'rlit tlPul:lislters, l99J.50. Lucltte AF: Ncw York Mt:dic,tl (.olle,qt',Valltalla, NY' (personal ()nununi(,tti( )t)).il. M;trkoft M, Farolt: A: Reilt,r sr,n)l),t,tltctic rlystrctphy s',tnclrcntt'. ()ral 5ur,t161 :2.1- )U, 1986.5). Mark<twitz S, Saitr.t K, Moskttt,itz 1,1,.\:Neurogeni<:,tlly nediated /r:,r(,rgc o/'plasma protein oc<-urs front bltxtc! w'ssels in clura rnater l;ut not brain. J Nt'ttrosci 7:41 29-11 36, 1 9875.1. M.ttltt:w, NT, Subits E, Nig.tnt Nl: Tr.;nsiorntation of ntigraine into dailvt lt,rtnit ,rre.rri.rr he,. ..\n.r/ysi.s ot l',,r( t()r\.I lt'aclacltr' )):(t(t 68, 198)\1oskotl;lz MA: The neurobiolc,,g,y otr'.r:;r'ulrr ltt',tct p,tin. Ann Net,rctl l6:I 57 I (tB, | 9fll\lttntt'ntlt,tler N1: t\t'urolog,y. St 2),119 .15-l Stuttgart; Thiente l'lttdicalPLt,ttlishers, 1990Pllllpy llt:, Hundcr (,(, : Rheunt,tt:tlog,i-(. ,1| Intcrvi('w,inp, and Phvsit aI l;:)..antin,r,tiolt ot tltt' loints ()ncl Ecl), p1t I.)5.t)h,; IarIt'IIthia : l\/.IJ. S,tundrtrs CoInp,)-|tr.. l9l[],t)rtrtt'rtit'ltl lA, DeRos,t C: Mt'chanital\r,r ( /1rrrr /'c,rspr'<'1ir.,r.-s in Furtttion.tl,'1n,rtoirrr, l) 5.5. Pltilade'lphia: lN.t3..5,turrtlr,rs ('orn1t,tny', I 995,?anlt JLl, /lt'nauid Ltl , Brandt P.A.. lyittrl '11': /ht, t'tft'ct ol trt't'zin14 ancl tha\rit)gt)n tl'tc rnir.'ny jl slllictn and r,tpillary,t'rtrlolhclirtrn ol tht' h.tnrstc,r c./rcc(ltottclt. (.rvtiltiology I t :510 516. t 97.1ti,rrnt'r EJ, Langer IJ, F_vis ML: .A,lvt:olart ,tr,il:ttion,tl osteopathosis. J Feriortontal Rt's 5.;-( t ()):.59 I tt0'1, I 986/loir.rcrls l\/: A lt)'l,xttht'sis on tltt' physit t I t t g i r'.t I l.'.t s i s fo r r'.r r-s,r/gi.r,t n,:! re l,tt cclltarns. l',tin )1:)()8 tl l, l()B(t/iu:,itlon /(i, 5lcvcrrs lC, Mill::r Rl l:t'lrxsoltlttrvngaal 1v;tsoglossLtpharvn,:.r', /, 1t,'r,;,)Lii,r. A strrcty r,t l,/ - (,]\(,.\...1rr lr Nctrrr.r/ 18:201 20.5, Il)t: 1/irl;irrlrrrllr (i: ()ltservations t:)n blinkrr'l/r,rr,.s. I Neurol Neurosurg P:;ychiatry,-!.i :().1 I (.t,!1. I ()6).'i,r1.rt'r /R M.tgec, KR: Freedrtr,q l'rontllt'trla<ltts, pp 1.5.1 154. Nen, York:-'iinton ,t .Schuslt'r, I ()Bl5<'lt,tllL:r l(': Tltt:,rrtltritides ri child-lttxxt. ln: IJttchanart WW, D,ick W(.'Icc/sJ, Rt,r t,nt Aclvanrr:s in Rht'unt,ttol()g\,, pp ll9 109. Edinburg,h: ChurchillI it',;ngstot;t', I98I.$/rr,/lt,// I D: Cltronic ctaily, head,ache.1"1t'rtrtt| 1)(Sttppl 2) :,)2,36, t 99.,1!,lttrrirtlyt;1t C-9: f)r'cerebrate rigic!ity.rntl rt:llt't t oorrli nation of nt(.tvent('nt.ll'ltvsiol r.Lond) 22:.J19 332, tljttB.'ir.r/,r AL, l\/illiants RI : N,lyofast.i,tl pain.sIlrr/r(;tncs.,!r'rlrolo11r, (t:(,t I ()-5, I ().56Solont:tn 5, Liltton Ii,9: .-\tr7-'it.r/ /tr.i.r/l,t,tin: l\ rt-victt,. -Scrrrirr ,\lr.trrc,l Biq):i J2 llB, l9iiu5oIrtntttn 5, Liyttt'tn R,9: Di,t1t,nosis,tnclp'atltolltysiolor,v Lti,rtiur.tine. ln : Drt,trtrr.rnrJ --! 1efl.), \1igr;i,t11 L1e',tclaclrc. Frev(rllioll .tncl \..1,tn,t1:,t'ntent, pp | -.J0.Eiascl, Stvitzr'rlancl: Nlar,:e,t L)ekk<:r,Inc'., I9()oStreip, 'lW', llillxtttrn ,\1, Nlit:;Ltnroto H:-Spr,:-lrrl.r rreorrr e I t:c t r i c t I ;t c t i v i t1t i t t 1.>o I y -nt yos i t i :;,) n ( | r I c r n Jl on rvosil i-s. rV u sc I efJrryr, -1./Jli l ;1 It.)79.Srleel flr//: Iht: tn:,tlrnent ol trigt:ntin.tlnt't;tr,tli4i,r (lir dLtult;ureur). N EnglJ Nled ) I 5(i); 1,71 L:7, I Li6[,tvlor ;\[:, Gibson l.\/f1, Cr,tngcr ttJ:I ltt' tnk'r,t< lio rr /tt'li,r,r,'r'n intra<-;tltillary.rrrtJ lrssut, k)r('['-s //r llrt' ttver,tll regiul;lIion ot interstittal tlu,;c! wtlunte. Iyntltltologr' (t:I ().' 20tJ, 1(.t7.1I r,t vr.' I l,l ('. .5irr ro,rr-s [ ) ( ) : N11'ot'a t i a I P ;t i n,rntl [,t\:slurttli,:tn. I lrt' T.r iF,gt'r froint/v1.tntr.tl. 1t1t )r)-L )0-1. 2(t.5.'galLin,ore:Willi,trns rt 14'iilins, iltli-lI rt.ttrltriclge ,t t( ). Lntli,)8 R(-: ,trtilan,nt,ttirrrr. ,1 Rr:r,ir'ry itl tht' I:'rctctss t'4th Ed),1tp I ,1.). ('ltit ago: (..!ttintt'ssr:nce Pul:lislting t"o.. lrtt ., l()9:lV'anrtant LI), L)rip115, RL): Long.te:rnt folIttv,t Ltl:. ()l t.r.tli('/tl.\ v'lto r('t eivc'dI (),0()ft s1tirtaL rrrt,sf hclir: s; :jt,n':lrt.rnrt' oft/r,, ti.,t., tl ittl,.t< r,ttti,t,' ltre,tLttt, ,11,,,td-J':.ltc ;rn(l rx utar ;tntl J!.tdil()ry difficul-tie:;). lt\,\1A ltt t' :5t16 .5,:) | , I t):t6Vtrilltitrct (.11, Kisnr:r (', Olt.'r'tlt T.M, Sa,r'lt:: L: I ltt' intcr,tction ()l' \r,earin,e, ntul-titoc,tl lt'nst:s rt,itlt Ittac! poslure andp.tin. l (')rtltolt Slxtrts P'hvs Ther 2.1(3):l9.l l':)(), I ()gt,\y'/ilson ,t'R: ('ltroni< nt:.)ck pain ,tnd c.-"r-\,1;rcgenic Itc,trl,tt.lte. Clin J P,titr .7:5-I I , l9t)ll4/ollc f': Iilsntsitis, tlbrontvalgia, ancl/lr{/-s('r//{)5k('/(:'t,r/ c/ist:,;'se. The r.urrt'nt-sLtlc r.rf tltt. filtrositis syt)clronre ArchI'h1,s ,4,1r,r1 llahabil 69t:5)7 5,1 | , I gBBZoltn [)A, ,Nlt'nnell Jt\,1: Diagnosis ,tnclPhysiL'al 7rt:,ttrnenl l,luscttloske!etall),tin. p1t I )rlt | )9, i \)() -19:t. Bostc'n:little., IJrown and Contys,tny,, 19t'(>i6b\J707l72-.17779.7l7B278\'olrrrrrc 2-,1 . NLulbcr.l . Ortobcr 1996 .JCTSP'l
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