Cervicalgia

NOTES ON THE STRUCTURE OF THE RACHIS

The vertebral column, also called rachis, is composed of 33-34 vertebrae. On the basis of the different configuration of the vertebrae it can be divided into four sections which, named in the cranio-caudal sense are: cervical, dorsal, lumbar, sacred. The first and third under physiological conditions form lordotic curves (curves of the column to posterior concavity) , while the other two form kyphotic curves (curves of the column with anterior concavity).

In the fetus, the spine appears as a single C-shaped curve. Even before birth, a cervical countercurve begins to appear (cervical lordosis), which will then develop after birth in parallel with the stages of acquisition of the ability to extend the head^[1]Bagnall, K. M., P. F. Harris, and P. R. Jones. “A radiographic study of the human fetal spine. 1. The development of the secondary cervical curvature.” Journal of anatomy 123.Pt 3 1977: … Continue reading ^[2]Been, Ella, Sara Shefi, and Michalle Soudack. “Cervical lordosis: the effect of age and gender.” The Spine Journal 17.6 2017: 880-888.. At the lumbar countercurve (lumbar lordosis) it develops in relation to the achievement of the upright position and walking.

The lordoses (cervical and lumbar), also called secondary curves, they allow to recover the horizontality of the gaze by counterbalancing the inclination given by the kyphotic curves. (dorsal and sacral), also called primary curves due to the fact which preserve the original trend of the first large fetal C, among other things they have the task of welcoming and protecting in their heart concavity, lungs and pelvic organs. The alternation of the primary and secondary curves gives the structure of the spine the ability to cushion the weight and to bear considerable levels of load stress.

THE CERVICAL SPINE

The rachis, at the cervical level, it has the function of guaranteeing the possibility of movement and, at the same time, cranial stability. The orientation of the head it is essential because the head is the seat of our sense organs, necessary for a cognitive relationship with the outside world. Eyes, ears, nose and mouth are promptly oriented towards the sources of the stimuli of our interest just come on movements of the cervical spine.

The cervical spine also has the task of protecting a vitally important structure: the spinal cord. This is the portion of the central nervous system that is located outside the skull and that we can consider to all intents and purposes as an extension of our brain. It is located within the spine, and extends to the second lumbar vertebrae.

The curvature of cervical lordosis under physiological conditions should be understood between 31° and 40°^[3]McAviney, Jeb, et al. “Determining the relationship between cervical lordosis and neck complaints.” Journal of manipulative and physiological therapeutics 28.3 2005: 187-193..

The vertebrae of the cervical spine, like all vertebrae of the spine, are named with alphanumeric abbreviations: an initial letter which indicates that it belongs to the reference spine section (C=cervical) followed by a number indicating the specific vertebra. The vertebrae are counted starting from the one closest to the skull: C1.

At the cervical level they are present 7 vertebrae (C1 – C7), functionally divided into upper regions (C1-C2) and lower (C3-C7).

The first vertebra, C1, due to its location it is also called Atlas. Whoever gave it this name was inspired by a mythological character, the titan who holds the world on his shoulders just as C1 holds our head.

It is a unique vertebra in its shape. No vertebral body or spinous process, it has the shape of a ring.

The structure of the joint between the atlas and the occiput (atlanto-occipital joint) mainly allows for a bending movement (circa 10°) and extension (circa 25°) of the boss. For this reason Atlas is also called "the vertebra of yes".

Aalso the second vertebra, C2, it has its own particular name in addition to the alphanumeric one: epistrophe, dal greco returns, che deriva da come back (to twist, turn). Like atlas, epistropheus is also characterized by a unique shape. From its structure an elongated process emerges above which takes the name of the tooth of the axis, which pivots to the rotational movement of the upper vertebra, the atlas.

The articulation that is thus determined in the relationship between these two vertebrae, la atlanto-epistrofea, allows a rotational movement of the head of about 45° to each side. For this reason the axis is also called "the vertebra of no". In reality, the atlanto-occipital joint also partially collaborates in the rotation of the head.

Between atlas and occiput and between axis and atlas, unlike what happens between the remaining vertebrae of the column, the intervertebral disc is absent. It is a structure that has the function of cushioning the weight and reducing the pressures that develop during movements.

The lower part of the cervical spine has vertebrae with similar characteristics. The inclination of the facet joints of the vertebrae of this section is such as to mainly allow the movement of flexion and extension of the head and lateral inclination.

All cervical vertebrae have lateral foramina to allow and guide the passage of the vertebral arteries which from the atlas then pass into the occipital foramen to supply the brain and of the vertebral veins which carry out the reverse path. The C7 vertebra has a smaller hole through which only the vertebral vein passes, because the vertebral artery begins to travel through the transverse holes only starting from the C6 vertebra. The C7 vertebra is also called the "prominent vertebra" due to its long spinous process. The size of the bodies of the cervical vertebrae is smaller than that of the dorsal and lumbar vertebrae because this section has to support less weight than the sections of the underlying column.

THE CERVICALGIA

Neck pain, neck pain, it can be limited to the cervical area but can also extend to the shoulder area and spread along an arm (cervicobrachialgia). Sometimes it is accompanied by numbness or loss of strength in the arms or hands.

At the epidemiological level, cervical pain is found to have a higher prevalence in high-income countries. People living in urban areas are more affected than those living in rural areas and women are more affected than men. The age group most at risk, according to some authors, is the one between 35 e i 49 years ^[4]Hoy, DG1, et al. “The epidemiology of neck pain.”Best practice & research Clinical rheumatology 24.6 (2010): 783-792..

Among the main risk factors for developing neck pain is the type of mechanical stress to which the cervical area can be subjected. The main causes of mechanical stress are due to maintaining the same position for long periods of time, especially if in an incorrect posture but sometimes also in a correct posture, to the execution of repetitive movements protracted over time and to traumas.

MAINTENANCE OF THE SAME POSITION FOR LONG PERIODS OF TIME

When we work on the computer for many hours in a row and we don't have a workstation that allows us to maintain correct posture, we subject some critical areas of our body to mechanical stress. Between these, the cervical tract is one of the most affected. An incorrect posture subjects a particular muscle group to continuous tension which in the long run can lead to contractures, continuous involuntary contractions of one or more muscles. It is a defense reaction that is triggered when the muscles are subjected to excessive work which undermines their physiological possibilities of response. At the muscle level, the contracture involves both evoked pain (which appears when making certain movements or on palpation) which is spontaneous and makes it difficult to carry out some movements involving contracted muscles. Wrong posture also leads to pain in the joint and ligament structures, because they are mechanically stressed and stressed for long periods of time beyond their function, and thus triggers inflammatory processes.

Actually, when we carry out activities that require the active maintenance of the same posture over time, even if we carry them out while maintaining correct posture, we should take breaks, stand up and interrupt the prolongation of a fixed posture. We are not structured to make beautiful figurines and a protracted static still has a negative impact on our body. Sitting for more than 95% working time seems to be an important risk factor for neck pain: scientific research has shown an increased risk of neck pain for people who work with their neck flexed by at least 20° for more than 70% of working time ^[5]Ariens, G. A. M., et al. “Are neck flexion, neck rotation, and sitting at work risk factors for neck pain? Results of a prospective cohort study.” Occupational and environmental medicine 58.3… Continue reading. Some authors, Moreover, found an increased risk of neck pain for those who carry out activities that cause eye fatigue ^[6]Caseminasab, Somaye, et al. “Neck pain: global epidemiology, trends and risk factors.” BMC musculoskeletal disorders 23.1 2022: 1-13., which are mainly sedentary activities performed by interacting intensively with the monitor of an electronic device.

LThe most harmful protracted activity for the cervical tract is interaction with the cell phone, both because of the amount of time that more and more people are dedicating to it, both due to the fact that the position that the neck assumes during this activity really puts our neck to the test. The diffusion of this tool and its massive use has led to a dizzying increase in the cases of rectification of the cervical curve but also the appearance of cases of curve inversion. Of the latter, before the advent of the cell phone, you only heard about it in manuals, but it was known that the probability of encountering a real clinical case was close to that of encountering a unicorn. Today, however, this series is well represented and constantly increasing.

A phase in which we all physiologically adopt a protracted posture over time is during sleep. The difference with the protracted postures of wakefulness is that in sleep we are normally in a relaxed position, our muscles are completely at rest, they do no active work to counteract gravity. It's not about the active maintenance of a posture. Even in sleep, however, problems could arise, in the event that the adopted posture involves the mechanical stretching of muscular structures, joint, ligaments or nerves. This can happen if the head is poorly positioned on an inadequate pillow which causes the neck to bend in a non-physiological way.

PERFORMANCE OF REPETITIVE MOVEMENTS PROTRATS OVER TIME

The same structures that are affected by prolonged active static undergo mechanical stress even if they are repeatedly and continuously stressed over time in a fixed manner. A repeated gesture does not allow adequate recovery times for the structures it solicits. This situation occurs frequently in athletes, who, in order to maintain and increase their performance levels, undergo training which involves the repetition of certain gestures for their improvement. But it also happens in work situations such as assembly lines and in all those comparable to them. In particular it seems that the highest risk activities are those that involve a repeated inclination and/or twisting of the trunk ^[7]Ariens, Geertie AM, et al. “Physical risk factors for neck pain” Scandinavian journal of work, environment & health 2000: 7-19. .

TRAUMA

In the case of trauma, unlike the previous examples where the time factor (the duration of the noxious stimulus) it was the decisive one, the mechanical stress is given byintensity of the stress exerted in a generally very short time. For the cervical spine, the most frequent and paradigmatic of the possible traumas is the flick ^[8]Caseminasab, Somaye, et al. Cit. that occurs in the event of a road accident. The head is violently and suddenly moved first backwards and then forwards, pulling all the muscle structures, ligamentous, nerves and joints of the neck.

DISEASES RELATING TO THE MUSCULOSKELETAL SYSTEM

mechanical stress, both acute and protracted over time, can induce or aggravate, in addition to muscle contractures and inflammatory phenomena affecting joints and ligaments, also pathologies affecting the neuromusculoskeletal system such as arthritic phenomena, discopatie degenerative, disc herniations, spondylolisthesis, spinal canal stenosis, radiology, temporomandibular joint disorders and fibromyalgia^[9]Caseminasab, Somaye, et al. “Neck pain: global epidemiology, trends and risk factors.” BMC musculoskeletal disorders 23.1 2022: 1-13., which are important risk factors for the development of neck pain. Spinal tumors can also induce neck pain due to the mass effect (the increase in pressure caused by a growing mass on the surrounding tissues), but this is a rather rare event.

degenerative disc disease

degenerative disc disease It is a disease affecting the intervertebral disc. The intervertebral disc is composed of the 90% of water and is formed by an external structure, the fibrous ring, which borders and contains a gelatinous internal nucleus called nucleus pulposus. During the day, when it is loaded, loses some of its hydration (in the evening we are less high than in the morning by about 1 centimeter) which fetches again at night when we are idle and the disk is off load. Degenerative disc disease is a phenomenon in which the disc undergoes dehydration. In reality, within certain limits, it is a physiological phenomenon linked to aging. ,

At birth, the percentage of water present in our body is very high (until the 75 %). This percentage decreases more and more over the years. In adults it is around 60-65% and in the elderly it can reach the 50 % even if it seems that in the centenarians it can even reach the 40%. Dehydration of the intervertebral disc reduces its volume and its shock absorbing capacity. This leads to a reduction in the distance between the vertebrae with consequent compression of structures such as the nerve roots that exit bilaterally between one vertebra and another. The reduced cushioning function of the discs makes the nerve roots particularly vulnerable, especially during activities such as walking, running or jumping, during which the lack of shock absorption is most evident. Sometimes the disc that has undergone dehydration and therefore crushing / deformation, can slip from its seat e, depending on the direction of slip, going to compress the nearby nerve roots, determining a compression syndrome which manifests itself in pain, sense of numbness, pins and needles, muscle weakness. The location of the symptoms depends on the roots involved. In the case of the cervical spine, the symptoms can also extend to the shoulders, in the arms and hands and headaches may also occur, dizziness and feeling of nausea.

SLIPPED DISC

The herniated disc it is due to the rupture of the fibrous ring and consequent leakage of the nucleus pulposus from inside the disc. This generates local inflammation that can irritate nearby nerve roots, e, depending on the extent and location, can go to mechanically compress the nerve roots or, in some cases, the medullary canal.

CERVICAL SPONDYLOSIS

In cervical spondylolisthesis is the sliding of a cervical vertebra on the underlying vertebra. It can be a congenital situation or it can be due to acute mechanical stress such as trauma or continuous mechanical stress of a postural type or given by the repetitive execution of movements that place inadequate stress on the cervical spine.

STENOSIS OF THE VERTEBRAL CANAL

Vertebral canal stenosis is a narrowing of the vertebral canal that contains the spinal cord and causes spinal cord compression same. An arthritic-degenerative type stenosis is present in the elderly with a certain frequency. However, it can also be due to a herniated disc, a spondylolisthesis, severe trauma to the spine, to malformations or deviations of the column (scoliosis) or to Morbo in Paget. Diabetes has been highlighted as a risk factor, obesity and smoking. The symptoms depend on the extent of the narrowing and on the marrow and possibly radicular suffering that this causes. The pain is usually located in the neck and shoulders, but it can come to radiate up to the hand (cervicobrachialgia). Strength and sensitivity deficits in the upper limbs may appear. In extreme cases it is necessary to intervene surgically to decompress the suffering structures. Depending on the cause of the stenosis, the intervention can be aimed at removing the herniated disc, stabilize a vertebra or perform a decompressive laminectomy.

TEMPOMANDIBULAR JOINT DISORDERS (ATM)

ATM riots^[10]Fougeront, Nicolas, and Bernard Fleiter. “Temporomandibular disorder and comorbid neck pain: facts and hypotheses regarding pain-induced and rehabilitation-induced motor activity… Continue reading they are a set of dysfunctional pictures affecting the temporomandibular joints (ATM) and masticatory muscles. ATM riots can cause neck pain, especially in the suboccipital region and this type of neck pain is often refractory to conventional treatments because it requires direct intervention at the TMJ level.

IMPORTANCE OF THE CONFORMATION OF THE CERVICAL CURVE

The ability to cushion the mechanical stresses to which our spine is subjected on a daily basis depends on the shape of its curves.

Maintain a physiological cervical lordosis (between 31° and 40°) is important for masticatory function, for breathing control, for vocal production, for eye movements and to better absorb the impact of the weight of the head especially during walking and running^[11]McAviney, Jeb, et al. “Determining the relationship between cervical lordosis and neck complaints.” Journal of manipulative and physiological therapeutics 28.3 2005: 187-193.. Cervical curves of less than 20° are associated with neck pain^[12]McAviney, Jeb, et al. “Determining the relationship between cervical lordosis and neck complaints.” Journal of manipulative and physiological therapeutics 28.3 2005: 187-193. and a recent review of the scientific literature^[13]Oakley, Paul A., et al. “Restoring cervical lordosis by cervical extension traction methods in the treatment of cervical spine disorders: a systematic review of controlled trials.” … Continue reading highlighted the effectiveness of physiotherapy interventions that include, among the treatment goals, l’ increase in the degree of curvature of the cervical lordosis in those patients in which it is reduced compared to the physiological range^[14] Been, Ella, Sara Shefi,and Michalle Soudack. Cervical lordosis. The effect of age and gender. The Spine Jounal 17.6.2017.

ROLE OF MYOFASCIAL TRIGGER POINTS IN THE ONset AND CHRONICIZATION OF CERVICALGIA

I trigger points (TrPs) are small areas of muscle tissue, a few millimeters wide, painful on palpation. TrPs can also cause referred pain (pain that occurs in an area distant from the one that evokes it). In some patients, a significant association was found between idiopathic neck pain and pain referred to trigger points in the posterior neck muscles, of the head and shoulders^[15]Fernandez-de-Las-Peñas, César, et al. “The role of myofascial trigger points in musculoskeletal pain syndromes of the head and neck.” Current pain and headache reports 11.5 2007: … Continue reading. In these cases the targeted treatment of TrPs has proven effective in counteracting the symptoms of neck pain^[16]recorded, Amit V., et al. “The efficacy of an integrated neuromuscular inhibition technique on upper trapezius trigger points in subjects with non-specific neck pain: a randomized controlled… Continue reading.

OTHER RISK FACTORS for neck pain highlighted by the scientific literature are:

Autoimmune diseases: rheumatoid arthritis, polymyalgia rheumatica, multiple sclerosis (SM), ankylosing spondylitis, systemic lupus erythematosus (THE), myositis and psoriatic spondylitis ^[17]Caseminasab, Somaye, et al. (Cit.)..
Arthrosis^[18]Manchikanti, Laxmaiah, et al. Age-related prevalence of facet-joint involvement in chronic neck and low back pain. Pain physician 11.1 2008 67.
Diabetes^[19]Jimenez-Garcia, Rodrigo, et al. Is there an association between diabetes and neck pain and lower back pain? Results of a population-based study. Journal of Pain Research 2018 1005-1015.
Stress^[20]Linton, Steven J. “A review of psychological risk factors in back and neck pain.” Spine 25.9 2000: 1148-1156, anxiety and psychological disposition towards pain.. Based on some prospective studies also, there would seem to be a correlation between some psychological conditions and the onset of acute pain, subacute and chronic both at the cervical level and in general also of the rest of the spine: stress, anxiety, depression ^[21]Caseminasab, Somaye, et al. (Cit.). but also the attitude towards pain were found to be significant risk factors ^[22]Linton, Steven J. (Cit.).. However, some authors point out that in reality it is extremely difficult to distinguish between cause and effect because on the one hand it is possible to hypothesize that certain conditions psychological factors are risk factors, on the other hand, it is necessary to acknowledge that persistent pain can give rise to psychological discomfort.^[23]Croft, Peter R., et al. “Risk factors for neck pain: a longitudinal study in the general population. ” Pain 93 3 (2001): 317-325..
Demographic characteristics, how age and gender may influence the prevalence and development of neck pain. The prevalence is higher in females and the age groups most affected, according to some authors, I'm 45-49 years for men and and 50-54 years for women ^[24]Caseminasab, Somaye, et al. (Cit.).. According to other authors, however, it would be the fasci between the 35 e i 49 years with differences in percentages between the two sexes. ^[25]Hoy, DG1, et al. (Cit.).
Cigarette smoke ^[26]Hogg-Johnson, Sheilah, et al. “The burden and determinants of neck pain in the general population: results of the Bone and Joint Decade 2000–2010 Task Force on Neck Pain and Its Associated… Continue reading ^[27]Hogg-Johnson, Sheilah, et al. “The burden and determinants of neck pain in the general population.” European Spine Journal 17.1 (2008): 39-51..

THE IMPACT OF LIFESTYLE ON CERVICALGIA: USEFUL TIPS.

If you have an office profession or occupation that involves sitting for long hours, is critical take recurrent breaks and at regular intervals in which you can stand up, walk to "stretch your legs". A few little tricks can help. For example, a good practice to adopt in the office may be to use a shared printer, in such a way that to take the things that are sent to print it is necessary to get up from the desk.

Make sure you have one mattress and a suitable pillow

Avoid conducting ato a sedentary life. At least walk 10.000 steps per day, 7.000 after i 60 years.

Maintain an adequate level of hydration ^[28]Oakley, Paul A., and Melissa L. Baird. “Do patients drink enough water? Actual pure water intake compared to the theoretical daily rules of drinking eight 8-ounce glasses and drinking half your… Continue reading. In conditions of dehydration, damage to various organs and systems can occur ^[29]Popkin, Barry M., Kristen E. D'Anci, and Irwin H. Rosenberg. “Water, hydration, and health.” Nutrition reviews 68.8 2010 439-458. ^[30]Benelam, B., and L. Wyness. “Hydration and health: a review.” Nutrition Bulletin 35.1 2010 3-25. ^[31]Perrier, Erica T. “Shifting focus: from hydration for performance to hydration for health.” Annals of Nutrition and Metabolism 70.Suppl. 1 2017 4-12. and according to some recent studies there would seem to be a correlation between dehydration and rachis pain ^[32]yaqoob, Uzair, et al. “Characteristics of back pain in young adults and their relationship with dehydration: a cross sectional study.” F1000Research 9.159 2020: 159.. The problem is that it is not simple to establish the right amount of liquids that we should take per day because there are too many variables to take into account^[33]Kalman, Douglas S., and Anna Lepeley. “A review of hydration.” Strength & Conditioning Journal 32.2 2010 56-63: the age, the sex, lifestyle (sports person, competitive athlete, sedentary person..), the climate of the place where you live, the time of year, the state of health (people with heart failure, for example, should limit their fluid intake and follow precise medical indications in this regard). Dieticians use formulas that provide a rough indication of how many liquids to take per day:

Using pounds as the unit of measure: half body weight in ounces. Eg, if the body weight is of 160 lb (72,6 kg) you should drink 80 ounces of water (non-alcoholic fluids) or 2,3 liters approx.
Using kg as the unit of measure: 30 ml x kg of body weight = ml per day. For example a person weighing 50 kg should drink 1,5 liters of water (non-alcoholic fluids) per day.

Follow a healthy diet. The importance of following a healthy diet to reduce the risk of diseases such as cancer, diabetes and cardiovascular disease is often highlighted in the various media, but one thing that is rarely said is that an inadequate diet can be a predisposing factor for the development of musculoskeletal pain and can contribute to their chronicity. ^[34]Elma, Omar, et al. “Chronic musculoskeletal pain and nutrition: where are we and where are we heading?.” Pm&r 12.12 2020 1268-1278. ^[35]Elma, Omar, et al. “Nutritional factors in chronic musculoskeletal pain: unravelling the underlying mechanisms.” British Journal of Anaesthesia 125.2 2020 e231-e233..

Stop smoking

THE PHYSIOTHERAPY

In the field of physiotherapy there are several possible methods of intervention, to be adopted according to the individual clinical case ^[36]Dam farm, Pia, et al. “Evidence of physiotherapy interventions for patients with chronic neck pain: a systematic review of randomised controlled trials.” International Scholarly Research… Continue reading:

Mobilizations of the cervical spine, dorsal, of the shoulders and rib cage.
Treatment of contractures of the intrinsic spinal muscles
Treatment of Myofascial Trigger Points ^[37]Dommerholt, New genes causing hereditary Parkinson’s disease or parkinsonism., Carel Bron, and Jo Franssen. “Myofascial trigger points: an evidence-informed review.” Journal of Manual & Manipulative Therapy 14.4 2006: 203-221. ^[38]Lavelle, Elizabeth Demers, William Lavelle, and Howard S. Smith. “Myofascial trigger points.” Anesthesiology clinics 25.4 2007: 841-851.
Stretching and muscle re-elasticization to restore an adequate range of motion of the neck in rotation, inclination and flexion-extension
Isometric exercises for the cervical spine
Breathing exercises
Pumping
Treatment of the temporomandibular joint
Postural ginnastica Mézières
Tecartherapy (anti-inflammatory and pain reliever)
Neuromuscular taping

Note[+]

Note
↑1	Bagnall, K. M., P. F. Harris, and P. R. Jones. “A radiographic study of the human fetal spine. 1. The development of the secondary cervical curvature.” Journal of anatomy 123.Pt 3 1977: 777.
↑2	Been, Ella, Sara Shefi, and Michalle Soudack. “Cervical lordosis: the effect of age and gender.” The Spine Journal 17.6 2017: 880-888.
↑3, ↑11, ↑12	McAviney, Jeb, et al. “Determining the relationship between cervical lordosis and neck complaints.” Journal of manipulative and physiological therapeutics 28.3 2005: 187-193.
↑4	Hoy, DG1, et al. “The epidemiology of neck pain.”Best practice & research Clinical rheumatology 24.6 (2010): 783-792.
↑5	Ariens, G. A. M., et al. “Are neck flexion, neck rotation, and sitting at work risk factors for neck pain? Results of a prospective cohort study.” Occupational and environmental medicine 58.3 (2001): 200-207.
↑6, ↑9	Caseminasab, Somaye, et al. “Neck pain: global epidemiology, trends and risk factors.” BMC musculoskeletal disorders 23.1 2022: 1-13.
↑7	Ariens, Geertie AM, et al. “Physical risk factors for neck pain” Scandinavian journal of work, environment & health 2000: 7-19.
↑8	Caseminasab, Somaye, et al. Cit.
↑10	Fougeront, Nicolas, and Bernard Fleiter. “Temporomandibular disorder and comorbid neck pain: facts and hypotheses regarding pain-induced and rehabilitation-induced motor activity changes.” Canadian Journal of Physiology and Pharmacology 96.11 2018: 1051-1059.
↑13	Oakley, Paul A., et al. “Restoring cervical lordosis by cervical extension traction methods in the treatment of cervical spine disorders: a systematic review of controlled trials.” Journal of Physical Therapy Science 33.10 2021: 784-794.
↑14	Been, Ella, Sara Shefi,and Michalle Soudack. Cervical lordosis. The effect of age and gender. The Spine Jounal 17.6.2017
↑15	Fernandez-de-Las-Peñas, César, et al. “The role of myofascial trigger points in musculoskeletal pain syndromes of the head and neck.” Current pain and headache reports 11.5 2007: 365-372.
↑16	recorded, Amit V., et al. “The efficacy of an integrated neuromuscular inhibition technique on upper trapezius trigger points in subjects with non-specific neck pain: a randomized controlled trial.” Journal of Manual & Manipulative Therapy 18.1 2010: 37-43.
↑17, ↑21, ↑24	Caseminasab, Somaye, et al. (Cit.).
↑18	Manchikanti, Laxmaiah, et al. Age-related prevalence of facet-joint involvement in chronic neck and low back pain. Pain physician 11.1 2008 67.
↑19	Jimenez-Garcia, Rodrigo, et al. Is there an association between diabetes and neck pain and lower back pain? Results of a population-based study. Journal of Pain Research 2018 1005-1015.
↑20	Linton, Steven J. “A review of psychological risk factors in back and neck pain.” Spine 25.9 2000: 1148-1156, anxiety and psychological disposition towards pain.
↑22	Linton, Steven J. (Cit.).
↑23	Croft, Peter R., et al. “Risk factors for neck pain: a longitudinal study in the general population. ” Pain 93 3 (2001): 317-325.
↑25	Hoy, DG1, et al. (Cit.).
↑26	Hogg-Johnson, Sheilah, et al. “The burden and determinants of neck pain in the general population: results of the Bone and Joint Decade 2000–2010 Task Force on Neck Pain and Its Associated Disorders.” Journal of manipulative and physiological therapeutics 32.2 (2009): S46-S60.
↑27	Hogg-Johnson, Sheilah, et al. “The burden and determinants of neck pain in the general population.” European Spine Journal 17.1 (2008): 39-51.
↑28	Oakley, Paul A., and Melissa L. Baird. “Do patients drink enough water? Actual pure water intake compared to the theoretical daily rules of drinking eight 8-ounce glasses and drinking half your body weight in ounces.” Journal of Water Resource and Protection 7.11 2015 883.
↑29	Popkin, Barry M., Kristen E. D'Anci, and Irwin H. Rosenberg. “Water, hydration, and health.” Nutrition reviews 68.8 2010 439-458.
↑30	Benelam, B., and L. Wyness. “Hydration and health: a review.” Nutrition Bulletin 35.1 2010 3-25.
↑31	Perrier, Erica T. “Shifting focus: from hydration for performance to hydration for health.” Annals of Nutrition and Metabolism 70.Suppl. 1 2017 4-12.
↑32	yaqoob, Uzair, et al. “Characteristics of back pain in young adults and their relationship with dehydration: a cross sectional study.” F1000Research 9.159 2020: 159.
↑33	Kalman, Douglas S., and Anna Lepeley. “A review of hydration.” Strength & Conditioning Journal 32.2 2010 56-63
↑34	Elma, Omar, et al. “Chronic musculoskeletal pain and nutrition: where are we and where are we heading?.” Pm&r 12.12 2020 1268-1278.
↑35	Elma, Omar, et al. “Nutritional factors in chronic musculoskeletal pain: unravelling the underlying mechanisms.” British Journal of Anaesthesia 125.2 2020 e231-e233.
↑36	Dam farm, Pia, et al. “Evidence of physiotherapy interventions for patients with chronic neck pain: a systematic review of randomised controlled trials.” International Scholarly Research Notices 2013
↑37	Dommerholt, New genes causing hereditary Parkinson’s disease or parkinsonism., Carel Bron, and Jo Franssen. “Myofascial trigger points: an evidence-informed review.” Journal of Manual & Manipulative Therapy 14.4 2006: 203-221.
↑38	Lavelle, Elizabeth Demers, William Lavelle, and Howard S. Smith. “Myofascial trigger points.” Anesthesiology clinics 25.4 2007: 841-851.