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PubMed1992

Some observations on whiplash injuries.

Motor vehicle accidents with a whiplash mechanism of injury are one of the most common causes of neck injuries, with an incidence of perhaps 1 million per year in the United States. Proper adjustment of head restraints can reduce the incidence of neck pain in rear-end collisions by 24%. Persistent neck pain is more common in women by a ratio of 70:30. Whiplash injuries usually result in neck pain owing to myofascial trauma, which has been documented in both animal and human studies. Headaches, reported in 82% of patients acutely, are usually of the muscle contraction type, often associated with greater occipital neuralgia and less often temporomandibular joint syndrome. Occasionally migraine headaches can be precipitated. Dizziness often occurs and can result from vestibular, central, and cervical injury. More than one third of patients acutely complain of paresthesias, which frequently are caused by trigger points and thoracic outlet syndrome and less commonly by cervical radiculopathy. Some studies have indicated that a postconcussion syndrome can develop from a whiplash injury. Interscapular and low back pain are other frequent complaints. Although most patients recover within 3 months after the accident, persistent neck pain and headaches after 2 years are reported by more than 30% and 10% of patients. Risk factors for a less favorable recovery include older age, the presence of interscapular or upper back pain, occipital headache, multiple symptoms or paresthesias at presentation, reduced range of movement of the cervical spine, the presence of an objective neurologic deficit, preexisting degenerative osteoarthritic changes; and the upper middle occupational category. There is only a minimal association of a poor prognosis with the speed or severity of the collision and the extent of vehicle damage. Whiplash injuries result in long-term disability with upward of 6% of patients not returning to work after 1 year. Although litigation is very common and always raises questions of secondary gain in patients with persistent symptoms, most patients are not cured by a verdict. Acute treatment of neck pain consists of ice for 24 hours followed by heat applications, pain pills, NSAIDs, and muscle relaxants. Trigger point injections can be beneficial in both the acute and the persistent phases. Use of cervical collars should probably be kept to a minimum during the first 2 to 3 weeks after the injury and then avoided. Early passive mobilization and range of motion exercises may accelerate recovery. Physical therapy and transcutaneous nerve stimulators may be helpful in reducing pain and improving movement.(ABSTRACT TRUNCATED AT 400 WORDS)

Diagnosis, Differential↗
PubMed1998

Phentolamine effect on the spontaneous electrical activity of active loci in a myofascial trigger spot of rabbit skeletal muscle.

OBJECTIVE: To investigate the effect of phentolamine, a sympathetic blocking agent, on the spontaneous electrical activity (SEA) recorded from a locus of a myofascial trigger spot (MTrS), equivalent to a human trigger point, in rabbit skeletal muscle. DESIGN: Randomized control trial. SETTING: A university medical laboratory. PATIENTS OR OTHER PARTICIPANTS: Nine adult New Zealand rabbits. INTERVENTION: In the experimental group phentolamine mesylate (1mg/kg) was injected into the external iliac artery, followed by flushing with normal saline. The control group was treated with normal saline instead of phentolamine using the same procedure. MAIN OUTCOME MEASURES: SEA was recorded from multiple active loci of MTrSs in the biceps femoris muscle: initially SEA in the same locus was recorded before and immediately after phentolamine (or normal saline) injection; then SEA was recorded from 25 different active loci. The mean of the average integrated signal (AIS) of SEA was analyzed, comparing the effects of phentolamine and normal saline on SEA. RESULTS: In the same active locus, the AIS of SEA showed statistically a linear decay with time after phentolamine injection, with a correlation coefficient of .56 at p < .05. However, no statistical relationship could be derived for the control group data with time by using regression analysis, probably because of large variations among the rabbits and movement artifacts during the experiment. In 25 different loci in the phentolamine group, the mean of the AIS of SEA (7.92 microV) was significantly lower than that of the control group (9.89 microV) at p < .05. CONCLUSIONS: The results support the hypothesis that the autonomic nervous system is involved in the pathogenesis of myofascial trigger points. The application of the AIS as an evaluation index seems to be feasible in the quantitative measurement of SEA.

Adrenergic alpha-Antagonists↗
PubMedDate not supplied

Sphenopalatine ganglion block for the treatment of myofascial pain of the head, neck, and shoulders.

BACKGROUND AND OBJECTIVES: This study examined the effectiveness of sphenopalatine ganglion block (SPGB) for myofascial pain syndrome of the head, neck, and shoulders using a double-blind, placebo-controlled, crossover study design with comparison to an internal standard consisting of trigger point injections (TPI). METHODS: Patients (n = 23) were randomly assigned to receive either: (1) SPGB with 4% lidocaine, then TPI with 1% lidocaine, and finally SPGB with saline placebo or (2) SPGB with saline placebo, then TPI with 1% lidocaine, and finally SPGB with 4% lidocaine. Each respective treatment within each protocol was given sequentially at 1-week intervals for both groups. Prior to the first treatment, all patients assessed their average intensity of pain and pain at that particular moment using a visual analog pain scale. Pain intensity and pain relief were reassessed 30 minutes after each treatment and at 6 hours, 24 hours and 1 week using visual analog pain and pain relief scales. Pain intensity and pain relief data were transformed into natural logarithm units, and the statistical significance of SPGB with 4% lidocaine versus SPGB with placebo, SPGB with 4% lidocaine versus TPI, and TPI versus SPGB with placebo were tested by mixed-model analysis of variance. The magnitude of the differences in pain intensity and pain relief ratings were also compared via computation of 95% confidence intervals. RESULTS: The analgesic effect of SPGB with 4% lidocaine was no better than placebo. Mixed-model analysis of variance revealed improved analgesia with administration of TPIs as compared to SPGB with 4% lidocaine and placebo over the entire week of observations (pain relief scores). CONCLUSIONS: This study suggests that SPGB with 4% lidocaine is no more efficacious than placebo and less efficacious than administration of standard trigger point injections in the treatment of myofascial pain of the head, neck, and shoulders.

Adult↗
PubMed1989

Measurement of pain threshold in patients with rheumatoid arthritis, osteoarthritis, ankylosing spondylitis, and healthy controls.

Pain threshold was measured using a pressure algometer in 126 subjects, of whom 54 were females and 72 males. These subjects included 18 males and 18 females with rheumatoid arthritis, 18 males and 18 females with osteoarthritis, 18 males with ankylosing spondylitis, and 18 male and 18 female healthy control volunteers. Six points were studied on each side of the body: 2 cm above the eyebrow on the forehead, lateral aspect of the arm at the insertion of the deltoid muscle, midpoint of the ulna, hypothenar eminence in the palm, midpoint of the quadriceps muscle, and midpoint of the antero-medial aspect of the tibia. None of these points corresponded to the "trigger" points in fibromyalgia. The pain threshold was statistically significantly higher in patients with ankylosing spondylitis than in patients with osteoarthritis, and these in turn were statistically higher than in the normal subjects. Patients with rheumatoid arthritis had significantly lower pain thresholds than the normal subjects. No laterality in pain threshold was identified, but females had in general a lower pain threshold.

Adult↗
PubMed2001

[Fibromyalgia].

The classification of fibromyalgia is based on the criteria of the American College of Rheumatology. For diagnostic reasons autonomic disturbances and mental features have to be considered. The distinction between fibromyalgia (tender points) and myofascial pain syndrome (trigger points) is essential. Internal and neurological disorders as a primary cause of fibromyalgia have to be excluded. The aetiology and pathogenesis of fibromyalgia still remain uncertain. The myopathological patterns in fibromyalgia are non-specific: type-II-fiber-atrophy, a slight increase in lipid droplets, a proliferation of mitochondria and a slightly elevated incidence of ragged red fibers. Biochemically alterations of the serotonin system and high levels of substance P in the cerebrospinal fluid of fibromyalgia patients are important. Animal experiments showed that the central stimulation by nociceptor input from muscles is exaggerated in skeletal muscle pain conditions, suggesting central hyperexcitability. The diagnosis of fibromyalgia requires a thorough exclusion of other rheumatologic and neurologic disorders. The differential diagnosis is complicated by an overlap to other chronic somatoform pain disorders.

Diagnosis, Differential↗
PubMed2000

Fibromyalgia-symptom or diagnosis: a definition of the position.

According to the American College of Rheumatology the diagnosis of fibromyalgia is based on criteria for the classification of fibromyalgia consisting entirely of clinical signs and symptoms. For diagnostic reasons autonomic disturbances and mental features have to be considered. The distinction between fibromyalgia (tender points) and myofascial pain syndrome (trigger points) is essential. Internal and neurological disorders as a primary cause of fibromyalgia have to be excluded. The etiology and pathogenesis of fibromyalgia still remain uncertain. The myopathological patterns in fibromyalgia are non-specific: type II fiber atrophy, an increase of lipid droplets, a slight proliferation of mitochondria, and a slightly elevated incidence of ragged red fibers. Initial reports on some allelic abnormalities in the serotonin system seem to highlight the important role of serotonin already presumed earlier. Significantly high levels of substance P in the cerebrospinal fluid of FM patients additionally support the impact of these neurotransmitters on both nociceptive and antinociceptive mechanisms.

Atrophy↗
PubMedDate not supplied

Recent advances in the understanding of acupuncture.

The controversy about acupuncture is familiar to us since its recent reintroduction into this country. Much of its philosophical concepts were taken at their face values as the bases for condemnation. Since I last reviewed these antiquated concepts in the light of modern medicine, much has developed. It seems that if the effects of acupuncture were transmitted along the peripheral nerves to the central nervous system, it would be more effective if applied segmentally to the site of noxious stimulation. Disruption of extralamniscal pathways would abolish its analgesic effect. The distant and nonsegmentally located acupuncture points exert their influences through the integrative efforts of the reticular formation and the thalamus. The demonstration of transmissibility of acupuncture analgesia through blood and cerebrospinal fluid in animals implicates the involvement of humoral factors. Since such an effect can be suppressed by naloxone or by hypophysectomy, endorphins are thought to be involved. Such laboratory evidences indeed begin to shed some light on a possible neurohumoral mechanism of acupuncture. The differences between acupuncture and hypnosis are discussed. Acupuncture points were compared with referred pain, trigger points and motor points of the skeletal muscles. Its possible uses for other than pain, such as drug addiction, alcoholism, etc. are also reviewed.

Acupuncture Therapy↗
PubMed2002

Immediate effects of dry needling and acupuncture at distant points in chronic neck pain: results of a randomized, double-blind, sham-controlled crossover trial.

To evaluate immediate effects of two different modes of acupuncture on motion-related pain and cervical spine mobility in chronic neck pain patients compared to a sham procedure. Thirty-six patients with chronic neck pain and limited cervical spine mobility participated in a prospective, randomized, double-blind, sham-controlled crossover trial. Every patient was treated once with needle acupuncture at distant points, dry needling (DN) of local myofascial trigger points and sham laser acupuncture (Sham). Outcome measures were motion-related pain intensity (visual analogue scale, 0-100 mm) and range of motion (ROM). In addition, patients scored changes of general complaints using an 11-point verbal rating scale. Patients were assessed immediately before and after each treatment by an independent (blinded) investigator. Multivariate analysis was used to assess the effects of true acupuncture and needle site independently. For motion-related pain, use of acupuncture at non-local points reduced pain scores by about a third (11.2 mm; 95% CI 5.7, 16.7; P = 0.00006) compared to DN and sham. DN led to an estimated reduction in pain of 1.0 mm (95% CI -4.5, 6.5; P = 0.7). Use of DN slightly improved ROM by 1.7 degrees (95% CI 0.2, 3.2; P = 0.032) with use of non-local points improving ROM by an additional 1.9 degrees (95% CI 0.3, 3.4; P = 0.016). For patient assessment of change, non-local acupuncture was significantly superior both to Sham (1.7 points; 95% CI 1.0, 2.5; P = 0.0001) and DN (1.5 points; 95% CI 0.4, 2.6; P = 0.008) but there was no difference between DN and Sham (0.1 point; 95% CI -1.0, 1.2; P = 0.8). Acupuncture is superior to Sham in improving motion-related pain and ROM following a single session of treatment in chronic neck pain patients. Acupuncture at distant points improves ROM more than DN; DN was ineffective for motion-related pain.

Acupuncture Analgesia↗
PubMed2000

Image analysis quantification of substance P immunoreactivity in the trapezius muscle of patients with fibromyalgia and myofascial pain syndrome.

OBJECTIVE: Substance P (SP), a neurotransmitter stored within the afferent nociceptive fibers, is likely to be involved in the pathogenesis of musculoskeletal pain. We investigated SP immunoreactive (SP-ir) nerve fibers in the upper trapezius of patients with fibromyalgia (FM) and myofascial pain syndrome (MPS) by immunochemistry. METHODS: Trapezius muscle obtained from tender points of 9 women with primary FM, from trigger points of 9 women with regional myofascial pain, and from 9 control women were immunostained with anti-SP sera. Quantitative evaluation was performed by computerized image analysis. RESULTS: No significant differences in the number of SP-ir areas were detected between groups (one way ANOVA: p = 0.2); in contrast, mean optical density (OD) of SP-ir showed a significant difference comparing the groups (one way ANOVA: p < 0.0001). Mean OD of the immunostaining for SP was statistically greater in trapezius muscle of patients with MPS (0.594 +/- 0.096) compared to specimens from patients with FM (0.436 +/- 0.140) (p < 0.05) and controls (0.314 +/- 0.105) (p < 0.05); mean OD of immunostaining for SP was greater in FM specimens than in controls (p < 0.05). CONCLUSION: Our results point to a peripheral hyperactivity of the peptidergic nervous system in FM as well as in MPS. These findings support the notion of pathogenetic involvement of the afferent nervous system in the development and perception of myofascial pain.

Adult↗
PubMedDate not supplied

Pain threshold in humans. A study with the pressure algometer.

Pain perception threshold (PPT) in the head was assessed with a pressure algometer in 40 control individuals (24 females and 16 males). Threshold was assessed at 11 symmetrical points on each side. The average threshold for each side was calculated, and differences between two sides were evaluated with an asymmetry index. Subjects were studied in relation to age and sex, and any difference in the symmetrical perception of pain on the head was registered. The deltoid muscle was chosen as a reference point, since it is rarely a site of trigger points. The reproducibility of the method was satisfactory. A significantly positive correlation was found between PPT value of the head and the deltoid muscle. There was no tendency to rise or fall in PPT during the same "session", which consisted of 3 separate complete measurements. The mean of mean values showed that there was little asymmetry as for the thresholds pertaining to the head in the total material. Age and sex apparently played little role as for the outcome of the test. The assessment of PPT in the head might be a useful tool in the study of lateralization of pain in unilateral headache syndromes.

Adult↗
PubMed1994

[The role computerized telethermography in the diagnosis of fibromyalgia syndrome].

Fibromyalgia syndrome is a form of extraarticular rheumatism of unknown origin; its diagnosis is fundamentally based on clinical and anamnestic findings, on characteristics of pain and on number and sites of tender points, very painful areas to palpation. At present there is no laboratory or instrumental test available for a more objective diagnosis. The Authors verified the utility of telethermography for fibromyalgia syndrome diagnosis to point out a possible specific pattern; in particular the tender points were studied, even to find some analogy to myofascial syndromes trigger points, which appear as hot spot to telethermography. The telethermographic patterns of 156 patients with fibromyalgia syndrome have been compared with tender point maps obtained from same subjects and with telethermographic data of patients affected by spine osteoarthritis and normal controls. The patients with fibromyalgia syndrome showed a non specific hyperthermic pattern, corresponding to painful muscular areas, comparable with pattern of osteoarthritic patients. This phenomenon can be interpreted as a greater thermic emission by hypertonic muscles. Therefore, telethermography in fibromyalgia syndrome cannot represent a basic diagnostic tool but can support the clinical diagnosis and play an important role in the follow-up of patients.

Adult↗
PubMed2005

The integration of acupuncture within medicine in the UK--the British Medical Acupuncture Society's 25th anniversary.

Acupuncture was first used in China, probable about 2000 years ago. When acupuncture first arrived in the West in the 17th century, the principles which the Chinese had used to explain its actions were at variance with current scientific knowledge of the body's structure and function. This led to the rejection of acupuncture by the medical profession in the UK, although individual practitioners adopted it with enthusiasm, usually needling the point of maximal tenderness to treat musculoskeletal pain. Acupuncture was more generally accepted in France and Germany, where the pioneering British physician Felix Mann encountered it in the 1950s. He then taught acupuncture to other medical practitioners and organised regular meetings in London, from which the British Medical Acupuncture Society, BMAS, emerged in 1980. The tradition of biannual scientific meetings has continued since then. The Society has many connections with prominent acupuncturists internationally and is a founder member of the International Council of Medical Acupuncture and Related Techniques (ICMART), and has hosted two world congresses. The Society was involved in standardisation of the meridian nomenclature published in 1990. The Society's scientific journal, Acupuncture in Medicine, was founded in 1981 and has gained international recognition, being indexed on several databases. The Society has established regular teaching courses at different levels, which lead to professional qualifications of Certificate and Diploma. The membership is now open to different health professionals, has grown steadily and now stands at nearly 2500. The Society is administered from offices in Cheshire and London. Many individual members have contributed to the Society's characteristic Western 'medical' approach to acupuncture in which needling is seen as a form of neuromuscular stimulation that owes little to traditional meridians or points. The Society has shown a particular interest in acupuncture for myofascial trigger point pain. Members of the Society have contributed to the evidence base of acupuncture with several books, clinical trials and reviews. The Society is optimistic that it will have an increasingly important role in promoting the use and scientific evaluation of acupuncture for the public benefit.

Acupuncture↗
PubMed1994

Effects of strong pulsed magnetic fields on the cardiac activity of an open chest dog.

The heart of an open chest dog was stimulated by strong magnetic fields which were damped sinusoidal pulses with the one-cycle period of 1.47 ms. Stimulation effects were detected by electrocardiograph (ECG) and arterial blood pressure as a function of the strength of the field, the triggering point in the cardiac cycle, and the position of a stimulating coil. The threshold for arrhythmias was a minimum for the stimuli triggered at the apex of the T wave and on the P wave in the ECG. Premature ventricular and premature atrial contractions occurred according to whether the coil was placed over the ventricles or the atria. Ventricular defibrillation can not be attained by the magnetic stimulus with the flux density of 9.2 T which was the maximum field used.

Animals↗
PubMedDate not supplied

At which stage of sensory recovery can a tingling sign be expected? a review and proposal for standardization and grading.

The phenomenon of paresthesia elicited by percussion of regenerating axons is usually associated with Tinel and Hoffmann, who both described it separately in 1915, although the same phenomenon had been described previously, in 1909, by Trotter and Davies. This sign is used widely, but its standardization is almost completely lacking, its grading is seldom used, and its reliability or validity is scarcely mentioned in the literature. The authors present a method of standardization and grading of the tingling response by means of a vibrostimulator, which permits precise localization of the trigger point and uniform stimulation. The tingling response may then be classified according to its location and to the magnitude threshold at which the response is triggered. In the distal part of the nerve, after neurotmesis repair, the tingling sign is graded T++ (tingling after a weak stimulus) and T+ (tingling only after a strong stimulus). At the site of the injury, the initial tingling sign is graded T0. The sign is graded T00 if, independent of recovery, a slight positivity persists at the initial site of injury. Grading of sensory recovery is poorly standardized, since different authors use different variations and modifications of existing classifications. The authors of this paper present a cross-matching of these classifications and propose to use Dellon's modification of Zachary's classification in eight stages, from S0 to S4. A discussion of the probability of eliciting a tingling sign during axonal regeneration concludes that the clinician can expect to trigger a T+ + sign when sensory recovery evolves from stage S0 to stage S1 and should no longer expect to trigger one when sensory recovery improves from stage S2+ to stage S3.

Fingers↗
PubMed2000

Interpersonal conflict and sarcasm in the workplace.

Violence and aggression in the workplace are problems that most Americans confront on a daily basis. The present study is an exploration of the predisposition to conflict in a work environment in which personality traits responsible for increased sarcasm and increased anger in response to sarcasm are identified. Participants represented two subdepartments within a city general hospital. The Keirsey Temperament Sorter (D. Keirsey, 1998) test for departmental temperament and a sarcasm survey designed by the author were used to test for frequency of sarcasm and anger in relation to differing categories of sarcasm. Angry reactions were gauged in relation to sarcasm directed at job performance, personal life, behavior, and appearance. Conclusions from this study point to many variables as causes for workplace anger; these include influences from organizational culture, work environment, psychological defense mechanisms, leadership decisions, stress, task orientation, and personality differences. Sarcasm trigger points leading to anger may be predicted based on a work group's personality composition. A homogeneous personality composition within a work group may involve factors such as personality characteristics common to a particular profession, organizational demands, and hiring practices.

Adult↗
PubMed2007

A clinical development paradigm for cancer vaccines and related biologics.

Therapeutic cancer vaccines are a heterogeneous group of complex biologics with distinctly different clinical characteristics than cytotoxic agents. The current clinical development paradigm used for oncology drug development is based on criteria developed for cytotoxic agents. More flexible and focused developmental guidelines are needed to address the unique characteristics of therapeutic cancer vaccines. Over the course of 1 year, the Cancer Vaccine Clinical Trial Working Group, representing academia and the pharmaceutical and biotechnology industries with participation from the US Food and Drug Administration, defined in a consensus process the cornerstones of a new clinical development paradigm for cancer vaccines and related biologics. Four major topics were addressed: (1) end points for clinical trials, (2) trial designs and statistical methods, (3) technical and developmental challenges, and (4) combination therapy. The proposed paradigm suggests therapeutic cancer vaccines to be investigated in 2 general types of clinical studies: proof-of-principle trials and efficacy trials. Proof-of-principle trials, which introduce a novel cancer vaccine into humans, should include a minimum of 20 or more patients in a homogenous, well-defined population in an adjuvant setting or without rapidly progressive disease in a metastatic setting to allow vaccines adequate time to induce biologic activity and should incorporate immune and molecular markers. Objectives should include initiation of a safety database, determination of dose and schedule, and demonstration of biologic activity as proof-of-principle. Biologic activity is defined as any effect of the vaccine on the target disease or host immune system using biologic markers as study end points, for example, clinical, molecular, or immune response. Immune response is demonstrated if determined in 2 separate, established and reproducible assays at 2 consecutive follow-up time points after the baseline assessment. If proof-of-principle trials show such immune response, or other biologic or clinical activity, efficacy trials may be initiated. If none of these end points is met, the clinical development plan should be reevaluated to decide if further development is warranted. Efficacy trials formally establish clinical benefit either directly or through a surrogate and are encouraged to be randomized studies. This is in contrast to single-arm phase 2 trials used for cytotoxic agents, which often use tumor response rate as the primary end point and historical controls as a comparator. Efficacy trials may use prospectively planned adaptive designs to expand from randomized phase 2 into phase 3 studies if well-defined trigger-point criteria are met, but the cost of incorporating such design elements should be carefully evaluated. Efficacy trials can also be exploratory randomized phase 2 trials or conventional phase 3 trials. In addition, conventional clinical end points can be adjusted to account for biologic features of cancer vaccines. The concept of efficacy trials allows for an early assessment of vaccine efficacy based on credible prospective data. This 2-phase developmental paradigm supports a more flexible, expeditious, and focused clinical developmental process with early and informed decision making. In addition, this report addresses clinical development challenges and issues for combination therapies.

Cancer Vaccines↗
PubMed1992

[Anatomical viewpoint and physiopathological aspects of Wolff-Parkinson-White syndrome].

Reviewing various histological and physiopathological conditions pertinent to the WPW syndrome, attention is focused on the particular position of the HIS bundle, which is entrapped in different densities of connective tissue and in a turning point of the a.-v. conduction. In particular it may be stretched between one fixed limit at its Tawara extremity and its opposite limit which is relied upon the atrial contraction just in the ventricular presystole. This mechanical moment, together with a pathological trigger point in the HIS bundle, could assume the abnormal function of a timing factor of a.-v. conduction as well of the intraventricular one. In a summary manner two diagrams make effort to give likeness of this pathological viewpoint to an observer who is rather sceptical about the histological genuiness of many accessory bundles.

Atrioventricular Node↗
PubMed1985

Chronic neck and shoulder pain. Focusing on myofascial origins.

Chronic neck and shoulder pain is a complex, multifactorial problem. Often many months have passed since its onset. During this time the patient may have seen many physicians and tried many medications, some with abuse potential. Most patients are depressed and have lost their ability to cope with the stresses of daily life. The goals of therapy are to enable patients to deal with the problem and to bring them to the point where pain is no longer the dominant factor in their lives. For patients with chronic neck and shoulder pain of myofascial origin, this is accomplished with a multi-disciplinary approach that incorporates use of psychotherapeutic techniques, nonsteroidal antiinflammatory medications, antidepressant drugs, trigger-point injection, and several physical therapy modalities.

Chronic Disease↗