Vol. 67, No. 5
375
Evaluation and Management of Cervical Spine Syndromes ALVIN BROWN, M.D. Detroit, Michigan
The cervical spine has definite characteristics which makes it more subject to pathology than any portion of the vertebral column. It is placed between the dorsal spine, which is relatively immobile, and the skull, which is a weight that must be balanced on the cervical spine. The skull is held in place by the supporting capsular, ligamentous and muscular structures. The special sense organs of smell, sight and hearing in the head make it necessary that the neck have great range of motion in all directions. The position and the mobility of the neck are, therefore, two important factors in its vulnerability to injury. Seven vertebrae form the lordotic portion of the vertebral column (cervical spine) with each two adjacent vertebrae and their interposed tissues forming a functional unit. Two of these functional units are totally unlike the others, the occipito-atlanto and the atlantoaxial units. The remainder of the cervical spine is formed by similar functional units. The units below the axis consist of an anterior weight bearing, shock absorbing portion and a posterior guiding-gliding section. The anterior portion of the functional unit comprises two vertebral bodies separated by a hydraulic shock absorbing system called the intervetebral disc. The posterior portion of the functional unit is composed of two vertebral arches, two transverse processes, a central spinous process, and paired articulations. The posterior facets (apophyseal joints) are in opposition and guide the movement of adjacent vertebrae. An added feature of the anterior functional unit is the presence of the joints of von Luschka, located along the posterior lateral margin of the vertebral end plates. These joints have no articular cartilage nor synovial fluid and are called pseudoarthroses.
The movements of the cervical spine consist of flexion, extension, lateral rotation and lateral bending. The cervical region from C4 to C6 is the most active and mobile. The greatest degree of flexion occurs in the mid cervical region at the C4-5 and C5-6 interspaces. Extension of the spine is a more diffuse movement, but the site of maximal angulation is at the C4-5 interspace. There is great normal variation in the sites influencing flexibility of the cervical spine. The spinal cord is encased in the vertebral column and in the cervical section of the cord, there are eight pairs of spinal nerves. The cervical nerves are formed by the union of dorsal and ventral roots which arise on corresponding surfaces of the spinal cord. These roots leave the cord within the spinal canal on a level with the intervertebral discs and merge into a mixed nerve before entering the intervertebral foramina. The mixed nerve then divides into an anterior primary ramus and a posterior primary ramus. The anterior primary rami of the upper four cervical nerves are concerned in the formation of the cervical plexus. The anterior primary rami from C5 to Ti are concerned with the formation of the brachial plexus. Motor function of the cervical nerves is fairly well defined but there is always an element of uncertainty of the sensory innervation due to the overlapping of dermatomes. This is especially true in the posterior sensory field. ETIOLOGY
Trauma is the most frequent cause of cervical spine pathology. Injuries to the spine are sometimes confined to the soft tissue structures and sometimes involve the soft tissues and skeletal structures. The most common types of traumatic cervical spine injuries are:
376
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION
1. Sprain - an injury to a joint and its surrounding ligaments 2. Strain - an injury to muscles and/or tendons 3. Dislocation - displacement of a bone forming a joint with or without injury to the surrounding ligaments 4. Subluxation - an incomplete dislocation 5. Fracture - a break in continuity of bones
Some non-traumatic causes of cervical spine pathology are: 1. Arthritis a. Degenerative joint disease (osteoarthritis) b. Rheumatoid arthritis (spondylitis) c. Gout d. Infectious - syphilis, gonorrhea, tuberculosis 2. Infectious diseases a. Osteomyelitis 3. Neoplasms - primary tumors are rare in the cervical spine 4. Metastatic lesions - Ca of the breast is most frequent 5. Torticollis - causes overstretching of ligamentous and capsular structures 6. Anomalies - predispose to mechanical stress by restricting motion in a circumscribed area a. Axial Atlanto-occipital Fusion - neurological signs may not appear until the 2nd or 3rd decade. Difficulty is caused by foraminal constriction with production of adhesions and ischemia b. Klippel-Feil Syndrome - shortness of neck resulting in reduction in number of vertebrae; usually causes no sensory symptoms c. Congenital Basilar Impression - invagination of the atlas into the floor of the posterior cranial fossa d. Acquired Basilar Impression (platybasia) - associated with Paget's disease e. Cervical Rib (Thoracic Outlet Syndrome) - compression of the neurovascular bundle between the cervical rib and the clavicle 7. Other Factors a. Abnormal laxness of joint structures b. Emotional stress c. Physical and mental fatigue
SYMPTOMATOLOGY
In most instances of cervical spine disorders, pain is the chief presenting symptom. Each patient may have his own peculiar way of relating his pain complaints, but whatever the description, it should be recorded. Well localized areas of pain are of diagnostic significance in the diagnosis of cervical root irritation, whereas, generalized and ill defined pains are not the result of nerve root irritation per se. When the patient states that he "hurts all over", a dubious attitude on the part of the examiner is justified. One must then make an attempt to have the patient localize the pain by asking specific questions. The character of the pain is important. It may be constant or intermittent. It may be aggravated by certain movements. It may be
SEPTEMBER, 1975
sharp, a dull ache, or a burning sensation. The patient may relate that changing positions, or taking an analgesic, or the use of heat give him some relief. Cervical root pain has been classified as neuralgic or myalgic. Irritation of the sensory portion of the nerve root causes neuralgic pain and myalgic pain is caused by irritation of the ventral motor nerve root. The area of sensation in neuralgic pain conforms to a specific skin area known as a dermatome. Ventral motor root pain (myalgic pain) generally appears proximally in the shoulder, axilla, and upper arm. It is described as a deep, boring, unpleasant sensation. This pain is vague and generally localized in deep tissues, i.e., muscles, tendons, and fascial planes known as a myotome. The exact mechanism of ventral root pain is unknown, however. Pain in and from the neck region is variously described and originates from various tissue sites. It is also produced by many different mechanisms. It can be felt directly in the neck or it can originate in the neck and be felt elsewhere. The numerous musculo-skeletal tissues in the neck capable of causing pain are: 1. Posterior Longitudinal Ligaments - posterior attachments of the vertebral bodies 2. Facet Articulations - apophyseal joints 3. Facet Capsules - capsule between apophyseal joints 4. Nerve Roots - (mentioned in above paragraph) 5. Anterior Longitudinal Ligaments - anterior attachments of vertebral bodies 6. Muscles - increased waste metabolites - ischemia 7. Interspinous Ligaments - attachments between spinous processes
For better localization of tervical pain origin, there are several trigger points: 1. A localized tenderness of the arches or the apophysis, particularly in fractures or infractions of the apophysis 2. Along the posterior spinous ligaments 3. Over the transverse processes, indicative of involvement of the intervertebral articulations 4. At the occiput behind the mastoid process, indicative of involvement of the greater occipital nerve
Other important symptoms of cervical spine pathology can be: 1. Stiffness - may be the result of joint involvement, nerve root irritation, or due accumulation of metabolites in muscles combined with ischemia 2. Numbness - results from the irritation of nerves serving a specific dermatome distribution 3. Muscle weakness - results from irritation of nerve fibers innervating specific musculature
Vol. 67, No. 5 4. Eye Symptoms a. Blurring of vision b. Lacrimation c. Eye ball pain
Cervical Spine Syndromes
Irritation of the cervical sympathetic supply to certain eye structures via plexuses surrounding the internal carotid artery and its branches
5. Ear symptoms Irritation of sympathetic a. Loss of fibers surrounding the equilibrium vertebral arteries or b. Tinnitus c. Partial vertebral insufficiency deafness 6. Throat Symptoms a. Difficulty in swallowing - can be due to swelling of neck structures, cervicioglossopharyngeal irritation, or tearing of the median raphe of the pharyngeal constrictor muscles. 7. Chest Symptoms a. Dyspnea - due to pain in some respiratory muscles innervated by cervical nerve roots 8. Heart Symptoms a. Tachycardia (palpatations) - due to irritation of the C-4 root supplying the diaphragm and pericardium or irritation of the cardiac sympathetic supply 9. Miscellaneous a. Nausea and vomiting b. Syncope - due to vertebral artery insufficiency EXAMINATION OF THE CERVICAL SPINE
The examination of the cervical spine with or without referred pain relies upon a carefully taken history and a well interpreted physical examination. Some of the elements of history taking were alluded to earlier. A thorough physical examination should include the
following: 1. Inspection 2. Palpation 3. Testing range of motion (pain and pain free) 4. Evaluation of muscle strength of cervical musculature and upper extremities 5. Neurological evaluation including examination of deep tendon reflexes, testing superficial sensation, deep sensation, vibratory sense, and the presence of cerebellar signs. It also involves a cranial nerve assessment and tests for Hoffman and Babinski signs.
Adjunctive tests perform confirmatory function at best and should always be interpreted in that light. Some of the important adjunctive tests are as follows:
1. X-ray Examination - true x-ray evaluation of the cervical spine can be done only by taking the following views: a. A-P views b. Lateral views c. Oblique views d. Open mouth for visualization of the atlas-axis region. (Note)Lateral views in full flexion and extension may sometimes reveal a subluxation not otherwise evident, but full agreement regarding the interpretation of these views is not standardized.
377
2. Myelography - provides structural information by viewing the contour of the dural canal, the patency of the nerve sleeves, the posterior extension of the disc and the bony protrusions into the spinal canal 3. Electromyography - provides functional information by measuring the electrical potential of the muscles 4. Discogram - injection of contrasting dye material into the disc 5. Discometric tests - injection of fluid into the disc. Discograms and discometric tests are technically difficult, discomforting to the patient, and may be damaging to the disc.
TREATMENT
Treatment of patients with the various cervical spine syndromes is highly individualized and predicated upon the accuracy of one's diagnosis. Obviously, through a thorough understanding of the anatomy, kinesiology, physiology, and pathology of the involved area, one will have the necessary tools for making a precise diagnosis. This understanding together with a thorough history and physical examination, including the adjunctive tests, provides one with the proper expertise for more rational management. General principles in the management of patients afflicted with cervical spine pathology are as follows: 1. Alleviation of pain and discomfort 2. Restoration of normal joint range 3. Conditioning and strengthening of involved musculature
Management of these conditions by nonsurgical means involves the judicious use of the following measures: 1. 2. 3. 4. 5.
Heat Cold Massage Therapeutic exercises Traction a. Motorized intermittent traction b. Hand controlled intermittent traction c. Continuous traction d. Traction for home use Immobilization Correction of posture Injections of local anesthetics Manipulation
6. 7. 8. 9. 10. Psychotherapy 11. Drugs
Surgical management of these conditions is generally in the hands of an orthopedic surgeon or a neurosurgeon. LITERATURE CITED
1. STEINDLER, A. The Cervical Pain Syndrome, in instructional Course Lectures, The Am. Acad.
(Concluded on page 387)
Vol. 67, No. 5
Child Therapists
health center have been presented. An attempt has been made to show both the advantages and disadvantages of employing such personnel as primary therapists. It is felt that our unit has made a modest attempt to maximize the strength and talent of our para-professional staff. In so doing, we have tried to provide a clinical service which is meaningful and effective in alleviating the mental suffering of our children. To quote Arnhoff, Rubenstein and Speisman with whom I disagree on some points (commenting on matching tasks with the capabilities of those available to perform them): "Often there seems little choice of who is to be trained, particularly, in as lowpaid an area as mental health service has traditionally been. Efforts to use the abilities of the underprivileged, the elderly, the unskilled, and the dropout must recognize both their strengths and their weaknesses."' The authors note that the sensitivity and compassion of many of these individuals are particularly appropriate to working in "custodial" institutions, often with children and usually with the retarded. I feel that there is a significant place for para-professionals outside of institutions. In fact, one could argue
2.
3. 4. 5.
6. 7.
387
that more, not less sophistication, sensitivity, and compassion are required to work with children and retardates both in and outside of custodial settings. We, as child psychiatrists, have a tremendous responsibility for supporting and structuring child care occupations, especially at the para-professional level. Para-professional manpower must not be wasted through overlap, inadequate training, lack of career mobility, or preparation for irrelevant occupations or already obsolescent skills. LITERATURE CITED
1. ARNHOFF, F. and E. RUBENSTEIN, and J. SPEISMAN, (eds.). Manpower for Mental Health. Chicago: Aldine, 1969. SEE ALSO 1. FEIN, R. The Doctor Shortage: An Economic Diagnosis. Washington, D.C.: Brookings Inst., 1967. 2. NATIONAL INSTITUTES OF MENTAL HEALTH, Public Information Branch, and Center for Studies of Child and Family Mental Health. Mental Health Services for Children. (Public Health Service Publ. No. 1844.) 1968. 3. PEARL, A., and F. RIESSMAN, (eds.). New Careers for the Poor: The Non-professional in Human Service. New York: The Free Press, 1965.
(Brown, from page 377) Considerations. Arch. Phys. M. and Rehab., 40: of Orthopedic Surgeons, Vol. XIV. Ann Arbor: 387-9, 1959. J. W. Edwards, 1957. 8. MICHELE, A. A. and J. J. DAVIES, F. J. JACKSON, R. The Cervical Syndrome. 2nd ed. GRUEGER, and J. M. LICHTOR. ScapulocosSpringfield, Ill.: Charles C Thomas, 1958. GRANT, J. D. B. An Atlas of Anatomy. 5th ed. tal Syndrome (Fatigue-Postural Paradox). N. Y. Baltimore: Williams and Wilkins, 1962. State J. Med., 50:1352p.6, 1950. INMAN, V. T., and J. B. de C. M. SAUN9. JOHNSON, E. W. and R. M. Wells, and R. J. DERS. Referred Pain from Skeletal Structures. J. Duran. Diagnosis of Carpal Tunnel Syndrome. Nerv. Ment. Dis., 99:660-7, 1944. Arch. Phys. M. and Rehab., 43:414-9, 1962. 10. McKeever, D. C. The So-called Whiplash Injury. SANDLER, B. Cervical Spondylosis as a Cause of Spinal Cord Pathology. Arch. Phys. M. and Orthopedics, 2:1960. 11. CAILLIET, R. Hand Pain and Impairment. Rehab., 42:650-660, 1961. Philadelphia, Pa.: F. A. Davis Co. 1971. ODOM, G. L. and W. FINNEY, and B. 12. CAILLIET, R. Neck and Arm Pain. Phil. Pa. WOODHALL. Cervical Disk Lesions, J. Am. Med. Ass., 166:23-8, 1958. F. A. Davis Co. 1971. 13. GRAY, H. Anatomy of the Human Body. 26th RUBIN, D. Head, Neck, and Arm Symptoms ed. Phil. Lea and Febiger, 1954. Subsequent to Neck Injuries: Physical Therapeutic
SUPPORT THE SCHOLARSHIP FUND
375
Evaluation and Management of Cervical Spine Syndromes ALVIN BROWN, M.D. Detroit, Michigan
The cervical spine has definite characteristics which makes it more subject to pathology than any portion of the vertebral column. It is placed between the dorsal spine, which is relatively immobile, and the skull, which is a weight that must be balanced on the cervical spine. The skull is held in place by the supporting capsular, ligamentous and muscular structures. The special sense organs of smell, sight and hearing in the head make it necessary that the neck have great range of motion in all directions. The position and the mobility of the neck are, therefore, two important factors in its vulnerability to injury. Seven vertebrae form the lordotic portion of the vertebral column (cervical spine) with each two adjacent vertebrae and their interposed tissues forming a functional unit. Two of these functional units are totally unlike the others, the occipito-atlanto and the atlantoaxial units. The remainder of the cervical spine is formed by similar functional units. The units below the axis consist of an anterior weight bearing, shock absorbing portion and a posterior guiding-gliding section. The anterior portion of the functional unit comprises two vertebral bodies separated by a hydraulic shock absorbing system called the intervetebral disc. The posterior portion of the functional unit is composed of two vertebral arches, two transverse processes, a central spinous process, and paired articulations. The posterior facets (apophyseal joints) are in opposition and guide the movement of adjacent vertebrae. An added feature of the anterior functional unit is the presence of the joints of von Luschka, located along the posterior lateral margin of the vertebral end plates. These joints have no articular cartilage nor synovial fluid and are called pseudoarthroses.
The movements of the cervical spine consist of flexion, extension, lateral rotation and lateral bending. The cervical region from C4 to C6 is the most active and mobile. The greatest degree of flexion occurs in the mid cervical region at the C4-5 and C5-6 interspaces. Extension of the spine is a more diffuse movement, but the site of maximal angulation is at the C4-5 interspace. There is great normal variation in the sites influencing flexibility of the cervical spine. The spinal cord is encased in the vertebral column and in the cervical section of the cord, there are eight pairs of spinal nerves. The cervical nerves are formed by the union of dorsal and ventral roots which arise on corresponding surfaces of the spinal cord. These roots leave the cord within the spinal canal on a level with the intervertebral discs and merge into a mixed nerve before entering the intervertebral foramina. The mixed nerve then divides into an anterior primary ramus and a posterior primary ramus. The anterior primary rami of the upper four cervical nerves are concerned in the formation of the cervical plexus. The anterior primary rami from C5 to Ti are concerned with the formation of the brachial plexus. Motor function of the cervical nerves is fairly well defined but there is always an element of uncertainty of the sensory innervation due to the overlapping of dermatomes. This is especially true in the posterior sensory field. ETIOLOGY
Trauma is the most frequent cause of cervical spine pathology. Injuries to the spine are sometimes confined to the soft tissue structures and sometimes involve the soft tissues and skeletal structures. The most common types of traumatic cervical spine injuries are:
376
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION
1. Sprain - an injury to a joint and its surrounding ligaments 2. Strain - an injury to muscles and/or tendons 3. Dislocation - displacement of a bone forming a joint with or without injury to the surrounding ligaments 4. Subluxation - an incomplete dislocation 5. Fracture - a break in continuity of bones
Some non-traumatic causes of cervical spine pathology are: 1. Arthritis a. Degenerative joint disease (osteoarthritis) b. Rheumatoid arthritis (spondylitis) c. Gout d. Infectious - syphilis, gonorrhea, tuberculosis 2. Infectious diseases a. Osteomyelitis 3. Neoplasms - primary tumors are rare in the cervical spine 4. Metastatic lesions - Ca of the breast is most frequent 5. Torticollis - causes overstretching of ligamentous and capsular structures 6. Anomalies - predispose to mechanical stress by restricting motion in a circumscribed area a. Axial Atlanto-occipital Fusion - neurological signs may not appear until the 2nd or 3rd decade. Difficulty is caused by foraminal constriction with production of adhesions and ischemia b. Klippel-Feil Syndrome - shortness of neck resulting in reduction in number of vertebrae; usually causes no sensory symptoms c. Congenital Basilar Impression - invagination of the atlas into the floor of the posterior cranial fossa d. Acquired Basilar Impression (platybasia) - associated with Paget's disease e. Cervical Rib (Thoracic Outlet Syndrome) - compression of the neurovascular bundle between the cervical rib and the clavicle 7. Other Factors a. Abnormal laxness of joint structures b. Emotional stress c. Physical and mental fatigue
SYMPTOMATOLOGY
In most instances of cervical spine disorders, pain is the chief presenting symptom. Each patient may have his own peculiar way of relating his pain complaints, but whatever the description, it should be recorded. Well localized areas of pain are of diagnostic significance in the diagnosis of cervical root irritation, whereas, generalized and ill defined pains are not the result of nerve root irritation per se. When the patient states that he "hurts all over", a dubious attitude on the part of the examiner is justified. One must then make an attempt to have the patient localize the pain by asking specific questions. The character of the pain is important. It may be constant or intermittent. It may be aggravated by certain movements. It may be
SEPTEMBER, 1975
sharp, a dull ache, or a burning sensation. The patient may relate that changing positions, or taking an analgesic, or the use of heat give him some relief. Cervical root pain has been classified as neuralgic or myalgic. Irritation of the sensory portion of the nerve root causes neuralgic pain and myalgic pain is caused by irritation of the ventral motor nerve root. The area of sensation in neuralgic pain conforms to a specific skin area known as a dermatome. Ventral motor root pain (myalgic pain) generally appears proximally in the shoulder, axilla, and upper arm. It is described as a deep, boring, unpleasant sensation. This pain is vague and generally localized in deep tissues, i.e., muscles, tendons, and fascial planes known as a myotome. The exact mechanism of ventral root pain is unknown, however. Pain in and from the neck region is variously described and originates from various tissue sites. It is also produced by many different mechanisms. It can be felt directly in the neck or it can originate in the neck and be felt elsewhere. The numerous musculo-skeletal tissues in the neck capable of causing pain are: 1. Posterior Longitudinal Ligaments - posterior attachments of the vertebral bodies 2. Facet Articulations - apophyseal joints 3. Facet Capsules - capsule between apophyseal joints 4. Nerve Roots - (mentioned in above paragraph) 5. Anterior Longitudinal Ligaments - anterior attachments of vertebral bodies 6. Muscles - increased waste metabolites - ischemia 7. Interspinous Ligaments - attachments between spinous processes
For better localization of tervical pain origin, there are several trigger points: 1. A localized tenderness of the arches or the apophysis, particularly in fractures or infractions of the apophysis 2. Along the posterior spinous ligaments 3. Over the transverse processes, indicative of involvement of the intervertebral articulations 4. At the occiput behind the mastoid process, indicative of involvement of the greater occipital nerve
Other important symptoms of cervical spine pathology can be: 1. Stiffness - may be the result of joint involvement, nerve root irritation, or due accumulation of metabolites in muscles combined with ischemia 2. Numbness - results from the irritation of nerves serving a specific dermatome distribution 3. Muscle weakness - results from irritation of nerve fibers innervating specific musculature
Vol. 67, No. 5 4. Eye Symptoms a. Blurring of vision b. Lacrimation c. Eye ball pain
Cervical Spine Syndromes
Irritation of the cervical sympathetic supply to certain eye structures via plexuses surrounding the internal carotid artery and its branches
5. Ear symptoms Irritation of sympathetic a. Loss of fibers surrounding the equilibrium vertebral arteries or b. Tinnitus c. Partial vertebral insufficiency deafness 6. Throat Symptoms a. Difficulty in swallowing - can be due to swelling of neck structures, cervicioglossopharyngeal irritation, or tearing of the median raphe of the pharyngeal constrictor muscles. 7. Chest Symptoms a. Dyspnea - due to pain in some respiratory muscles innervated by cervical nerve roots 8. Heart Symptoms a. Tachycardia (palpatations) - due to irritation of the C-4 root supplying the diaphragm and pericardium or irritation of the cardiac sympathetic supply 9. Miscellaneous a. Nausea and vomiting b. Syncope - due to vertebral artery insufficiency EXAMINATION OF THE CERVICAL SPINE
The examination of the cervical spine with or without referred pain relies upon a carefully taken history and a well interpreted physical examination. Some of the elements of history taking were alluded to earlier. A thorough physical examination should include the
following: 1. Inspection 2. Palpation 3. Testing range of motion (pain and pain free) 4. Evaluation of muscle strength of cervical musculature and upper extremities 5. Neurological evaluation including examination of deep tendon reflexes, testing superficial sensation, deep sensation, vibratory sense, and the presence of cerebellar signs. It also involves a cranial nerve assessment and tests for Hoffman and Babinski signs.
Adjunctive tests perform confirmatory function at best and should always be interpreted in that light. Some of the important adjunctive tests are as follows:
1. X-ray Examination - true x-ray evaluation of the cervical spine can be done only by taking the following views: a. A-P views b. Lateral views c. Oblique views d. Open mouth for visualization of the atlas-axis region. (Note)Lateral views in full flexion and extension may sometimes reveal a subluxation not otherwise evident, but full agreement regarding the interpretation of these views is not standardized.
377
2. Myelography - provides structural information by viewing the contour of the dural canal, the patency of the nerve sleeves, the posterior extension of the disc and the bony protrusions into the spinal canal 3. Electromyography - provides functional information by measuring the electrical potential of the muscles 4. Discogram - injection of contrasting dye material into the disc 5. Discometric tests - injection of fluid into the disc. Discograms and discometric tests are technically difficult, discomforting to the patient, and may be damaging to the disc.
TREATMENT
Treatment of patients with the various cervical spine syndromes is highly individualized and predicated upon the accuracy of one's diagnosis. Obviously, through a thorough understanding of the anatomy, kinesiology, physiology, and pathology of the involved area, one will have the necessary tools for making a precise diagnosis. This understanding together with a thorough history and physical examination, including the adjunctive tests, provides one with the proper expertise for more rational management. General principles in the management of patients afflicted with cervical spine pathology are as follows: 1. Alleviation of pain and discomfort 2. Restoration of normal joint range 3. Conditioning and strengthening of involved musculature
Management of these conditions by nonsurgical means involves the judicious use of the following measures: 1. 2. 3. 4. 5.
Heat Cold Massage Therapeutic exercises Traction a. Motorized intermittent traction b. Hand controlled intermittent traction c. Continuous traction d. Traction for home use Immobilization Correction of posture Injections of local anesthetics Manipulation
6. 7. 8. 9. 10. Psychotherapy 11. Drugs
Surgical management of these conditions is generally in the hands of an orthopedic surgeon or a neurosurgeon. LITERATURE CITED
1. STEINDLER, A. The Cervical Pain Syndrome, in instructional Course Lectures, The Am. Acad.
(Concluded on page 387)
Vol. 67, No. 5
Child Therapists
health center have been presented. An attempt has been made to show both the advantages and disadvantages of employing such personnel as primary therapists. It is felt that our unit has made a modest attempt to maximize the strength and talent of our para-professional staff. In so doing, we have tried to provide a clinical service which is meaningful and effective in alleviating the mental suffering of our children. To quote Arnhoff, Rubenstein and Speisman with whom I disagree on some points (commenting on matching tasks with the capabilities of those available to perform them): "Often there seems little choice of who is to be trained, particularly, in as lowpaid an area as mental health service has traditionally been. Efforts to use the abilities of the underprivileged, the elderly, the unskilled, and the dropout must recognize both their strengths and their weaknesses."' The authors note that the sensitivity and compassion of many of these individuals are particularly appropriate to working in "custodial" institutions, often with children and usually with the retarded. I feel that there is a significant place for para-professionals outside of institutions. In fact, one could argue
2.
3. 4. 5.
6. 7.
387
that more, not less sophistication, sensitivity, and compassion are required to work with children and retardates both in and outside of custodial settings. We, as child psychiatrists, have a tremendous responsibility for supporting and structuring child care occupations, especially at the para-professional level. Para-professional manpower must not be wasted through overlap, inadequate training, lack of career mobility, or preparation for irrelevant occupations or already obsolescent skills. LITERATURE CITED
1. ARNHOFF, F. and E. RUBENSTEIN, and J. SPEISMAN, (eds.). Manpower for Mental Health. Chicago: Aldine, 1969. SEE ALSO 1. FEIN, R. The Doctor Shortage: An Economic Diagnosis. Washington, D.C.: Brookings Inst., 1967. 2. NATIONAL INSTITUTES OF MENTAL HEALTH, Public Information Branch, and Center for Studies of Child and Family Mental Health. Mental Health Services for Children. (Public Health Service Publ. No. 1844.) 1968. 3. PEARL, A., and F. RIESSMAN, (eds.). New Careers for the Poor: The Non-professional in Human Service. New York: The Free Press, 1965.
(Brown, from page 377) Considerations. Arch. Phys. M. and Rehab., 40: of Orthopedic Surgeons, Vol. XIV. Ann Arbor: 387-9, 1959. J. W. Edwards, 1957. 8. MICHELE, A. A. and J. J. DAVIES, F. J. JACKSON, R. The Cervical Syndrome. 2nd ed. GRUEGER, and J. M. LICHTOR. ScapulocosSpringfield, Ill.: Charles C Thomas, 1958. GRANT, J. D. B. An Atlas of Anatomy. 5th ed. tal Syndrome (Fatigue-Postural Paradox). N. Y. Baltimore: Williams and Wilkins, 1962. State J. Med., 50:1352p.6, 1950. INMAN, V. T., and J. B. de C. M. SAUN9. JOHNSON, E. W. and R. M. Wells, and R. J. DERS. Referred Pain from Skeletal Structures. J. Duran. Diagnosis of Carpal Tunnel Syndrome. Nerv. Ment. Dis., 99:660-7, 1944. Arch. Phys. M. and Rehab., 43:414-9, 1962. 10. McKeever, D. C. The So-called Whiplash Injury. SANDLER, B. Cervical Spondylosis as a Cause of Spinal Cord Pathology. Arch. Phys. M. and Orthopedics, 2:1960. 11. CAILLIET, R. Hand Pain and Impairment. Rehab., 42:650-660, 1961. Philadelphia, Pa.: F. A. Davis Co. 1971. ODOM, G. L. and W. FINNEY, and B. 12. CAILLIET, R. Neck and Arm Pain. Phil. Pa. WOODHALL. Cervical Disk Lesions, J. Am. Med. Ass., 166:23-8, 1958. F. A. Davis Co. 1971. 13. GRAY, H. Anatomy of the Human Body. 26th RUBIN, D. Head, Neck, and Arm Symptoms ed. Phil. Lea and Febiger, 1954. Subsequent to Neck Injuries: Physical Therapeutic
SUPPORT THE SCHOLARSHIP FUND
