Troels S. Jensen, M. D., Ph. D and Helge Kasch, M. D.

Background

During the last decades, there has been an increased focus on whiplash injury, an injury resulting from acceleration-deceleration forces acting on the neck. Whiplash injury is usually seen after rear-end car-collisions, but other types of mishaps may act similar on the neck. There is great variability among different prospective studies, on the short-term impact and the long-term effect of whiplash injury on physical and psychological well-being, and work capacity. At present, the mere existence of the so-called late whiplash syndrome has been widely debated (1). Extrinsic factors, such as type of insurance system (2), and preconceived notion of whiplash in society (3) (4), may profoundly influence the outcome of whiplash injury.

Pain after whiplash injury

Neck pain which is reported in 28-90% (4, 5), and headache in 19-50% (4,6) of whiplash injured subjects are among the most prominent complaints in the so-called late whiplash syndrome. Headache and neck pain had totally disappeared after 20 days in Lithuania (4), whereas a Swiss study (7) reported neck pain in 25% after two years follow-up. (7)

Neck-pain in whiplash is usually described as musculoskeletal, (8) and often confined to the posterior region of the neck. (9) However, there is growing evidence that a nociceptive pain type could be explanatory for long-term pain development. Theoretically, central as well as peripheral sensitisation might play a role. Whiplash injured patients had significantly higher scores on both intensity and quality of cold-induced pain and shorter duration regarding time of immersion in cold water compared with healthy controls (10). Recently, central sensitisation has been reported in so-called late whiplash syndrome

Prognosis was worsened in a Swiss study in patients with previously known neck pain, tension-type headache or migraine. (6) Tension-type headache and migraine involve peripheral and probably segmental/central sensitisation (12) (13). A neurophysiologic prospective study reported a transient anti-nociceptive-reflex dysfunction in the jaw which was normalised after 6 months. Segmental affection of the brainstem, or more likely the upper cervical medulla, with affection of subnucleus caudalis is a possible explanation for above findings. (14) Long-lasting pain relief was reported in late whiplash syndrome after subcutaneous sterile water injections in tender-points confined to neck and shoulder (8). This suggest that activation of anti-nociceptive systems reduces pain in late whiplash syndrome. The above findings support the existence of peripheral and central dysfunction of nociceptive processing following acute and late whiplash injury.

Neck mobility after whiplash injury

Impaired neck movement was related to poor outcome after 1 year. (7,9). Measurement of cervical neck mobility (CROM) discriminated chronic whiplash injured from healthy controls with a sensitivity of 77% and a specificity of 82% (15). However, the possible predictive role of reduced neck mobility in the acute phase for subsequent development of chronic symptoms are not known.

The present study

In this study, we prospectively followed 141 consecutive whiplash and 40 ankle distortion injured subjects after one week, 1, 3, 6 andl2 months with assessment of pain on a VASO _-100 scale, recording of symptoms and measurement of pain/tenderness in deep structures by means of palpation and pressure algometry. Neck mobility and work capacity of neck muscles were also assessed. Accounting for traumatic distress, we balanced the design of the study using a control group exposed to a trauma at distance from the neck (ankle distortion).

Results

Pain was present with a high frequency, but a low intensity in both whiplash and ankle injured. Whiplash injury is generally a benign condition with a high recovery rate, but a minority are still disabled after one year.

Focal, but not generalised sensitisation to musculoskeletal structures was present until three months, but not 6 months after whiplash injury. Probably, sensitisation does not play a major role for development of late whiplash syndrome. Pressure algometry (Somedic) and palpation are useful, clinical tools in evaluation of neck and jaw pain in acute whiplash injury.

Neck mobility is reduced immediately after, but not 3 months after a whiplash trauma. There is an inverse relationship between headache and neck mobility and between neck pain and neck mobility during the first six months after acute whiplash injury. A minor group who did not recover had, however significantly reduced neck mobility throughout the observation time, and this study shows that whiplash injured persons with reduced cervical- range-of-motion are at risk for long-term disability with a high sensitivity and persons exposed to whiplash injury with initial normal neck mobility almost all recover within one year.

References

(1) Stovner LJ The Nosologic status of the whiplash syndrome a critical review based on a methodological approach Spine 1996 21(23) 2735 46

(2) Cdssidy JD Carrol LJ Cote P Lernstra M Berglund A Nygren A Effect of eliminating compensation for pain and suffering on the outcome of insurance claims for whiplash injury New England Journal of Medicine 2000 , 342(16) 1179 86

(3) Ferran R Kwan 0 Russel AS Pearce JM Schrader H The best approach to the problem of whiplash ⁷ One Ticket to Lithuania, please Clin Exp Rheum 1999 17 321 6

(4) Obeheniene D, Schrader H Bovim G Miseviciene I Sand T Pain after whiplash a prospective controlled inception cohort study J Neurol Neurosurg Psychiatry 1999 66 279 83

(5) Hildmgsson C Soft-tissue injury of the cervical spine 1990 Umea University Medical Dissertations, New Series No 296

(6) Radanov BP Sturzenegger M Di Stefano G Schmdng A Aljinovic M Factors influencing recovery from headache after common whiplash BMJ 1993 307 652 5

(7) Radanov BP Sturzenegger M Predicting recovery from common whiplash Eur Neurol 1996 36(1) 48-51

(8) Bym C Olsson I Falkheden L, Lmdh M Hosterey U Fogelberg M Linder L Bunketorp 0 Subcutaneous sterile water injections for chronic neck and shoulder pain following whiplash injuries The Lancet 1993 , 341 449 52

(9) Sturzenegger M DiStefano G Radanov BP Schnidng A Presenting symptoms and signs after whiplash injury the influence of accident mechanisms Neurology 1994 1994Apr 44 4) 6884) 693

(10) Lee J Giles K Drummond PD Psychological disturbances and an exaggerated response to pain in patients with whiplash injury J Psychosom Res 1993 1993 37 2) 105-2) 110

(11) Koelbaek Johansen M Graven Nielsen T Schou Olesen A Arendt-Nielsen L Generalised muscular hyperalgesia in chronic whiplash syndrome Pain 1999 83(1) 229 34

(12) Jensen R Mechanisms of spontaneous tension type headaches an analysis of tenderness pain thresholds and EMG Pain 1996 64 251 6

(13) Jensen K Tuxen C Olesen J Pencranial muscle tenderness and pressure pain threshold in the temporal region during common migraine Pain 1988 35 65 70

(14) Keidel M Rieschke P Jupter M Diener HC Pathologischer Kierferoffnungsreflex nach HWS beschleumgungsverletzung Nervenarzt 1994 65 241 9

(15) OsterbauerPJ Long K RibaudoTA PetermannEA FuhrAW Bigos SJ Yamaguchi GT Three dimensional head kinematics and cervical range of motion in the diagnosis ot patients with neck trauma J Manipulative Physiol Ther 1996 19(4) 2317

WHIPLASH INJURY IN LITHUANIA (a prospective controlled inception cohort study)
Diana Obeheniene Kaunas Medical University, Lithuania

Objectives Since 1928 when Crowe described the whiplash mechanism in rear end car collision for the first time, it has been assumed that a cluster of chronic symptoms, including neck pain, headache, cognitive impairment, and tempotomandibular joint dysfunction can be caused by this trauma Despite numerous investigations and recurring controversies, the validity of this late whiplash syndrome is, however still doubtful Until now almost all studies have included patients who consulted a physician with complaints that were attributed to such an injury If such a study was done in a western country, the expectation of chronic symptoms and the chance of financial gain could act as confounding factors In Lithuania, there is a little awareness of the notion that chronic symptoms may result from rear end collisions via the so called whiplash injury After most such collisions no contact with health service is established An opportunity therefore exists to study postraumatic pain without the confounding factors present in western societies

 Methods. 210 victims of a rear end collisions were identified from the daily records of the Traffic Police Department of Kaunas City consequently The records describe the circumstances of the accident and the vehicle damage Neck pain and headache were evaluated by mailed questionnaires within 7 days after the accident, after 2 months, and after 1 year As controls, 210 sex and age matched subjects were randomly taken from the population register of the same geographical area and evaluated for the same symptoms immediately after their identification and after 1 year

On the end of prospective investigation the plan of the study was extended in order to investigate the prevalence of temporomandibular joint dysfunction after whiplash injury because of recent publications debating on that problem Therefore the questionnaires with socialdemographic questions, follow-up questionnaires have been sent to both accident victims and controls on an average 27 months after the accident All were asked about presence and frequency of temporomandibular Joint dysfunction symptoms, such as jaw pain jaw sounds, pain in or near ear(s), jaw locking tinnitus, facial pain, dissnes/vertigo, and bruxism

 Results Pain shortly after car accident was reported by 47% of accident victims , 10% had neck pain alone, 18% had neck pain together with headache, and 19% had headache alone The median duration of the initial neck pain was 3 days and maximal duration 17 days The median duration of headache was 4,5 hours and the maximum duration was 20 days After 1 year, there were no significant differences between the accident victims and the control group concerning frequency and intensity of these

symptoms. In the accident victim group 2,4% reported jaw pain on 1 day or more per month compared to 3,3% in the control group. Only one (0,6%) accident victim and 2(1,1%) controls had daily jaw pain. There were also a low prevalence of complaints in 1 day or more per month or daily complaints in both the accident victim group and control group for jaw sounds, pain in or near the ear(s), jaw locking, tinnitus, and facial pain. Dizzness/ vertigo on 1 day per month or more was reported by 18,2% of the accident victims and 26,1% of the controls. No accident victim and only 3 controls reported bruxism every night or almost every night.

 Conclusion. In a country were there is no preconceived notion of chronic pain arising from rear end collisions, and thus no fear of long term disability, and usually no involment of the therapeutic community, insurance companies, or litigation, symptoms after an acute whiplash injury are self limiting, brief, and do not seem to evolve to the so-called late whiplasdh syndrome.

References

(1) Bovim G, Schrader H, Sand T. Neck pain in the general population. Spine 19 : 1307-09, 1994.

(2) Deans GT, Magalliard JN, Kerr M, Rutherford WH. Neck sprain- a major cause of disability following car accidents. Injury 18 : 10-2, 1987.

(3) Ewing CL, Thomas DJ, Lustick L, et al. The effect of the initial position of the head and neck on the dynamic responce of the human head and neck to Gx impact acceleration. Proceedings of the Nineteenth Stapp Car Crash Conference ; Society of Automotive Engineers, 1975 :487-512. SAEpaper#751157.

(4) Ewing CL, Thomas DJ, Lustick L. Multiaxis dynamic response of the humanhead and neck to impact acceleration. Proceedings of the AGARD conference 253 ; 1978 November ; France. 1979 ; A5 : 1-27. 91.

(5) Ferrari R, Russell AS. The whiplash syndrome- common sense revisisted. J Rheumatol 24 (4): 618-23, 1997. ( 24 HSP) (48 RF) Gobel H, Petersen- Braun M, Soyka D. The epidemiology of headache in Germany : a nationwide survey of a representative sample on the basis of the headache classification of the International Headache Society. Cephalalgia 14 : 97-106, 1994.

(6) Ferrari R, Schrader H, Obelieniene D. Prevalence of temporomandibular disorders associated with whiplash injury in Lithuania. Oral surgery, oral medicine and oral pathology 87 ; 653-657 : 1999.

(7) Kolbinson DA, Epstein JB, Burgess JA. Temporomandibular disorders, headaches. And neck pain follawing motor vehicle accidents and the effects of litigation review of the literature. Journal of Orofacial Pain. 1996 ; 10 : 101-25.

(8) Macnab I. Acceleration injuries to the cervical spine. J Bone Joint Surg 8 : 1797-99, 1964.

(9) Norris SH, Watt I. The prognosis of neck injuries resulting from rear-end vehicle collisions. J Bone Joint Surg 65 : 608-11, 1983.

(10) Obelieniene D, Schrader H, Bovim G, Miseviciene I, Sand T. Pain after Whiplash : a controlled prospective inception cohort study. J Neurol Neurosurg Psychiatry 1999 ; 66 : 279-84.

(11) Pearce JMS. Whiplash injury : a reappraisal. J Neuro Neurosurg Psychiatry 52 : 1329-31, 1989.

(12) Probert TCS, Wiesenfeld D, Reade PC. Temporomandibular pain dysfunction disorder resulting from road traffic accidents : an Australian study. Int J Oral Maxillofac Surg 1994 : 26 : 338-41.

(13) Spitzer WO, Skovron ML, Salmi LR et al. Scientific monograph of the Quebec Task Force on Whiplash- Associated Disorders. Spine 20 (suppl8) : 1S-73S, 1995.

(14) Stovner LJ. The nosological status of the whiplash syndrome : A critical review based on a methodological approach. Spine 21 : 2735-46, 1996.

(15)Schrader H, Obelieniene D. Bovim G, et al. Natural evolution of late whiplash syndrome : outsidethe medicolegal context. Lancet 1996 ;347 : 1207-11.

LONG-TERM FLUCTUATIONS OF PRESSURE PAIN THRESHOLDS IN HEALTHY MEN, NORMALLY MENSTRUATING WOMEN AND USERS OF ORAL CONTRACEPTIVES.
Hans Isselee. Antoon De Laat, Kris Bogaerts, Roeland Lysens. Fac.Physical Education, School of Dentistry and Dept.Biostatistics, Cath. Univ. of Leuven, B-3000 Leuven, Belgium.

Aim of investigation: To evaluate wether the pressure pain threshold (PPT) in masticatory muscles of symptom-free subjects was influenced by hormonal fluctuations.

Methods: The PPT was measured with an electronic algometer during at least ten consecutive menstrual cycles in 10 women using oral contraceptives and 10 women not using oral contraceptives, with a regular menstmal cycle (26-31 days). In addition, 10 men were measured in a regular pattern over a period of one year. All subjects were symptom-free with an age range between 18 and 39 years. Measurement sessions were held during 3 different cycle phases and each session consisted of 4 consecutive PPT measurements. The PPTs of the masseter, temporalis and thumb muscles were compared between groups, hormonal phases, the 4 consecutive measurements for each muscle point per session and time by means of a linear mixed model (SAS).

Results: No significant changes of PPTs over time were found for the masseter (p=0.8419) and temporalis muscles (p=0.2786). There was no significant difference in variance for the masseter (p=0.6250), temporalis (p=0.9705) and thumb (p=0.7446) between the 3 groups. The PPTs of all muscles were significantly lower during the perimenstrual phases in the two female groups. No significant differences were found between the follicular and luteal phases.

Conclusions: The results have shown a very good consistency of the PPTs over a long time period, both in males and females. Considering the menstrual cyle as a unit, significant differences were observed during the perimenstrual days.

SCREENING FOR PERSONS AT RISK AFTER ACUTE WHIPLASH INJURY
Helge Kasch. Flemming W. Bach, Troels S. Jensen. DPRC, Dept.of Neurology, Aarhus Univ. DK-8000 Denmark

Aim: In a prospective study, we wanted to estimate the accuracy of predictors of recovery and disablement after acute whiplash injury.

Methods: 141 whiplash injured persons exposed to rear-end collision car accident classified as WAD grade I - II, and 40 controls sustaining acute non-sport ankle distortion were examined after 1 week, 1, 3, 6, 12 months. At first examination, the following 5 measures were recorded: 1) non-painful neurological symptoms, 2) present pain on a VAS scale, 3) psychometric variables (Millon Behavioral Health Inventory), 4) work load capacity of neck muscles during flexion and extension, 5) active cervical range of motion (CROM).

Results: 12% had not returned to normal level of activity after one year. Cox regression analysis showed that reduction in CROM was the only significant factor for time to recovery after whiplash injury (P<0.009). Other factors:work load, pain intensity, number of neurological symptoms, abnormal psychometric score, age>31y, gender, speed-difference (>26km/h) during collision did not significantly influence on recovery. Sensitivity of positive test (reduced CROM) =72.7%, accuracy=89.4%. Specificity was high = 99.2% for combination of severe initial present pain (>54 on VAS scale) + large number of neurological symptoms, yielding an accuracy =93.6%. The last result must be cautiously interpreted as Cox-regression only found CROM to be of prognostic value after acute whiplash injury.

Conclusion: Cervical range of motion has acceptable sensitivity for detecting disability after whiplash injury = 72.7%, accuracy=89.4%. Persons with reduced CROM after acute whiplash injury are at risk for long-term disability.

THE TREATMENT OF PAIN WITH LOW-POWER LASSERS IN THE DEGENERATIVE CHRONIC RHEUMATISM
Eleonora Sogorescu. M.D.; Dorin Danciu, M.D.; Eugenia Dumitrescu, M.D. Balneology and Medical Rehabilitation Clime of Calimanesti-Caciulata, ROMANIA

Aim of investigation: The most important symptom in the degenerative rheumatic affections is pain. The principal aim of the treatment with low-frequency lassers is eliminating the pain and reducing the inflammatory process.

Methods: A lot of 130 patients has been taken into study, cured in our clinic during 1999, which presented the following distribution in the degenerative chronic rheumatism: at hand level-46; at hip - 35 cases; at knee - 28 cases; at leg - 21 cases. The clinical parameter of pain has been quantified depending on its presence (0 points), inconstancy (1 point), or absence (2 points) and a clinical score of pain has been estimated, from 0 to 6 points. The other clinical parameters (inflammation, mobility limitation, loss of muscular power) are linked with the pain and quantified by a general clinical score from 0 to 15 pts. Low-power lassers have been used from the “BTL-Romania” company, equipment supplied with a microprocessor-controlled semiconductor diode having an infrared emmision ray of 50mW, working in a DC or pulsatory mode with a density of 3-5 J/cm². An average of 10 to 12 treatment sessions have been conducted daily or on a two-day basis. Based on the two clinical scores an evaluation has been effected at the beginning, in the middle and at the final period of the treatment - the obtained results have been statistically interpreted. Regarding the clinical score of pain, we considered of high gravity those cases that scored 0 to 2 pts, of medium those scored 3 to 4 pts, of little those scored 5 to 6 pts

Results: At the beginning, the pain repartition on classes of gravity has been as follows: high-68 cases(52.3%); medium-39(30%); low23(17.6%). At the end of the treatment, the mentioned repartition has been as follows: high-8 (6.1%); medium-15(11.5%);low-107(82.3%). It is to be observed that the weigh of the high-gravity cases has been diminished significantly, from 52.3% to 6.1%, thus confirming the efficiency of the treatment of low-power lassers on the clinical pain parameter

Conclusions: The degenerative chronic rheumatism is a frequently met affection in medical practice. Pain is the first symptom which determines the patient to appeal for a medical consulting. The favourable evolution of pain parameter pleads itself for the biostimulatory effect of the lasser therapy, especially on the production of beta-endorphmes with the interferrence of the pain stymulus. Pain from the superficial joints (hand, leg) is more receptive to lasser therapy than that one from the profound joints (hip, knee).

EARLY REVIEW OF PATIENTS AWAITING TOTAL HIP OR KNEE REPLACEMENT SURGERY - INDICATIONS TO ALTER PRIORITY ON WAITING LIST.
Carry Lewis. Pain Clinic and Department of Anaesthesia, New England Regional Hospital. Armidale, NSW. 2350. Australia.

Aim of investigation: To establish an early joint assessment clinic for orthopaedic patients awaiting hip or knee arthroplasty in order to improve patient preparation and waiting list management and to compare our experience with a 1996 Scottish study.

Method: A multi-disciplinary team assessed 48 patients as soon as possible after their referral for surgery, frequently over a year prior to operation, optimised their physical status and home situation and changed their priority when indicated.

Results: 91.79r of Australian patients presented with osteoarthritis compared with 50.5% of Scots and 4.1% of Australians and 42.25% of Scots (p < 0.0001) had rheumatoid arthritis. Most patients planned active pursuits post-operatively though 45 of 48 had co-morbidities and referrals to optimise treatment were made in 18 cases. The length of the waiting list. approximately 16 months for routine cases concerned 31.25%. Curtailment of a valued occupation was followed frequently by psychosocial deterioration and among those patients only having 0 -I residual occupations psychosocial deterioration warranting urgent re-prioritisation occurred in 10 of 13 (p < 0.025) and soon another was prioritised as urgent. All those (6) with 2 or more residual valued occupations did not deteriorate psychosocially nor did any of them require a change in prioritisation (p < 0.05).

Conclusions: Early pre-operative assessment and review is worthwhile, being accepted throughout this health region as a permanent service, which is cost-neutral. At review 15 of 48 patients had their priority altered, most frequently from 'routine' to 'urgent' due to psychosocial deterioration considered secondary to forced curtailment of a valued occupation.

CT-GUIDED INJECTIONS OF BOTULINUM TOXIN TYPE A IN THE TREATMENT OF MYOFASCIAL AND PSEUDORADICULAR PAIN
Matthias A.Lutze SPINE GROUP Dept.of Neurosurgery Schluterstr. 38 D-10629 Berlin

Aim of investigation: The present prospective study aims at determining whether CT-guided intramuscular injections of botulinum toxin type A (BTX-A) enable safe and efficient relief from myofascial and cervical/lumbar pseudoradicular pain.

Methods: CT-monitormg during outpatient injection procedure permits the quick placement of the 22-G-needle tip precisely in the center of the involved muscle belly by avoiding the risk of intravascular, intrapleural or perineural application. Correct instrument positioning is checked by applying contrast medium. 21 patients (age range: 31-83 years; 10 female, 11 male) received a total of 35 injections into affected muscle groups, e.g. longissimus thoracis and iliocostalis lumborum muscles, pinformis muscle, iliopsoas muscle, trapezius and levator scapulae muscle. The standard trigger point dose was BTX-A (BOTOX®, Merz) 50-100 U in 2 mL pysiological saline with 4 mL 0.5% bupivacaine per site, maximum 3 sites.

Postinterventional physiotherapy program includes early passive stretching regimen and a subsequent active exercise period.

Results: Clinical follow-up after 1, 2, 3, 6 and 12 months post-treatment revealed lasting and marked (> 70%, visual analogue scale) pain relief and improved mobility in 72% of the patients. The quality of life was assessed as .good' to .excellent' by 67% of all patients on the basis of a multimodal outcome score 6 months after the intervention.No side effects were reported.

Conclusions: With strict indicational criteria, CT-assisted injection of BTX/A enables highly selective and safe reduction of refractory myofascial pain. Preliminary clinical results have been promising thus far.

CONSERVATIVE CAUSAL THERAPY OF SHOULDERJOINT ARTHROSIS WITH ACUPUNCTURE, IN COMBINATION WITH NEURALTHERAPY, TENS AND "SYNVISC" (SYNOVIA SUBSTITUTE):
MODIFIED WHO - STEPSCHEME, IN COMBINATION WITH ACUPUNCTURE, NEURALTHERAPY, TENS AND "SYNVISC" (SYNOVIA SUBSTITUTE) FOR CAUSAL TREATMENT OF THE SHOULDERJOINT ARTHROSIS, AFTER TRANG (WITH FRIENDLY SUPPORT OF THE FIRMS GOEDECKE, WYETH AND BIOMATRIX)
Dr. med. Trang-Xuan Nguyen. medical specialist in general medicine, gynecology, obstetrics and special pain therapy, Friedlander Weg 51, 37085 Gottingen, Germany, in co-oporation with Prof. Hejo Eckel, Medical Superintendent of the radiological unit and Medical Director at the Protestant Hospital Gottingen, An der Lutter 24, 37075 Gottingen, Germany.

Aim of investigation: For many sportsmen and -women and also for craftsmen, the shoulderjoint arthrosis means the end of their career since conservative treatment with cortisone-injection, immobilization or surgery does not always shows the desired results and the postsurgical pains, especially pain on weight bearing are always considerable and the relapse rate is very high. The aim of this investigation is to show an effective, practicable and less stress causing therapy thus avoiding surgery.

Methods: The cure was achieved in a very high number of patients exclusively with the combination of neural therapy, acupuncture, transcutaneous electrical nerve stimulation and synovia subsitute and without the necessity of surgical intervention. The neuraltherapy was applied as epidural anesthesia in the region between C4 and C7, spinal nerve block or block of the brachial plexus and local infiltration. The additional therapy of TENS, salve, antiphlogistic following the modified WHO-Stepscheme in combination with acupuncture and neuraltherapy after TRANG improved the success of treatment. Thus even more no patient needed surgery.

Results: The described treatment of the shoulderjoint arthrosis combining for the first time causal therapy and substitution of synovia by ,,Synvisc" in this place is also highly effective for relapses after surgical treatment of rupture of the rotator cuff and impingement syndrome.

Conclusion: correctly applied, this new treatment of shoulderjoint arthrosis should be given priority to classical therapies since it causes lower costs and less stress for the patient.

Acknowledgments: Our special thanks to the firms Goedecke, Wyeth and Biomatrix, Germany, for their friendly support.

OSTEOARTROSIS CHRONIC PAIN. COMPLIANCE INDEX (CI) AS A METHOD OF COMPARATIVE MEASURING FOR THERAPY EFFECTIVENESS.
Maurizio Evangelista. Domenico Camaioni. Universita Cattolica del Sacro Cuore, Istituto di Anestesiologia e Rianimazione, 00168, Roma. Italia.

Aim of Investigation: In a patient group with chronic osteoartrosis pain, to determine the compliance index (CI) difference between tramadol and NSAIDs drugs.

Methods: In the setting area of the Center for the Study of the pathophysiology and for the therapy of pain in Catholic University of Rome, we have studied a group of one hundred patient with osteoartrosis pain. The group was composed by 46 males and 54 females, mean age 67.4 yrs; all the patients have experienced treatment with NSAIDs and with tramadol. In this study, to establish the effectiveness of any treatment we propose a simple method of scoring that is Compliance Index obtained by the ratio between the number of provisions daily true assumed and the total number of givings, daily prescribed; CI range will be: max=l, min.=0. The period of observation has been of four mounths.

Results: The prolonged use of NSAIDs is associated with significant adverse effects that represent the most common cause of drop out of the therapy. The CI score that we have noticed for this drug is 0.77 (185/240) Tramadol is a synthetic opioid analgesic, which also modulates monoaminergic mechanism in the inibitory pain pathways, resulting in a synergistic analgesic effect. The CI score that we have noticed for this drug is 0.94(226/240).

Conclusions: This is an ongoing study and the results about validation data and procedures of CI will be presented at the meeting.

THE RELATION BETWEEN COMPLAINTS, CLINICAL DIAGNOSIS AND ISOMETRIC SHOULDER MUSCLE ENDURANCE IN A POST-OFFICE WORKER POPULATION.
Røe.C.. Steingrimsdetween complaints, clinical diagnosis anDep of Physiol, National Institute of Occupational Health, 0033 Oslo, Norway, *Section for Health Science, University of Oslo, Norway.

Aim of investigation: To examine the stability of complaints from the musculoskletal system in workers over time, and to relate the complaints to the medical diagnosis of musculoskeletal disease and to isometric shoulder muscle endurance.

Methods: 69 counter staff post office employees volunteered to participate. The workers reported musculoskeletal complaints on a standardised questionnaire at inclusion. A standardised medical examination was performed, including reports of pain on visual analogue scales (0-100; 0=no pain, 100= worst possible pain) and endurance of isometric shoulder abduction. The same physicians, blinded for the conclusions of the initial medical examination, performed a follow up examination of 36 of the workers after 1 year. These 36 workers also performed muscle contractions and standardised data-terminal work in the laboratory.

Results: There was a significant correlation between the reported complaints in the questionnaires at inclusion and pain scores during the medical examination (p<0.05). In the medical examination, 81% of the subjects reported musculoskeletal complaints during the last week, 37% reported pain in the neck and shoulder, and 33% reported low back pain, while only 8 subjects received a diagnosis of musculoskeletal disease. The complaints remained in all except 3 subjects at the follow-up examination after 1 year. Shoulder abduction endurance was inversely correlated to complaints (r=-0.38, p<0.01) and correlated to tender points in the muscles (r=0.38, p<0.01).

Conclusions: Musculoskeletal complaints are stable over time. Information in questionnaires and medical examinations are corresponding, but few workers fulfil the criteria for a medical diagnosis of musculoskeletal disease. Functional measurements as muscle endurance correspond to a larger extent with complaints than the medical diagnostic criteria. Hence, we would argue for implementation of muscle function measurements in future work with diagnostic criteria sets in the field of musculoskeletal research.

EFFECT ON THE LEVEL OF PGE2 AND LTB4 IN HUMAN MASSETER MUSCLE WITH MYALGIA BY INTRAMUSCULAR INJECTION OF GLUCOCORTICOID
Britt Hedenberg-Magnusson. Malin Emberg and Sigvard Kopp, Clinical Oral Physiology, Karolinska Institutet, 14104 Huddinge, Sweden.

Aim of investigation: To determine whether the intramuscular levels of prostaglandin E2 (PGE2) and leukotriene B4 (LTB4) was influenced by local glucocorticoid administration and if changes in this level is associated with changes in pain and hyperalgesia or other clinical aspects.

Methods: Eighteen patients with fibromyalgia and seventeen with localized myalgia of the temporomandibular system were examined before and after local treatment with glucocorticoides regarding resting pain, pressure pain tolerance, maximum voluntary mouth opening and pain upon maximum voluntary mouth opening. Venous blood samples were obtained and analysed with respect to plasma concentrations of prostaglandin E2 (PGE2) and leukotriene B4 (LTB4). Three consecutive samples were obtained from the masseter muscle by microdialysis and the dialysates were analysed with respect to PGE2 and LTB4 concentration.

Results: Concentrations of PGE2 differed significantly before and after treatment on both sides side in fibromyalgia (p=0.0093 and p=0.049 respectively) as well as LTB4 on the most tender side (p=o.0015). No changes were found in the patients with localized myalgia. Concerning the clinical variables significant changes were found before and after treatment in both groups on the most tender side regarding pain upon digital palpation (p=0.005 and p=0.022 respectively), pressure pain threshold (p=0.026 and p=0.002) as well as in resting pain and pressure pain tolerance in the fibromyalgia group ( p=0.06 and p= 0.017 respectively)

Conclusion: This study shows that local glocucorticoid treatment reduces pain and hyperalgesia in painful masseter muscle and significantly decrease the levels of PGE2 and LTB4 in patients with fibromyalgia. No changes was found in localized myalgia which indicate different pathophysiology behind this condition and fibromyalgia.

Acknowledgements: Supported by the Swedish Dental association.

ASPECTS OF IMPAIRMENTS, DISABILITIES AND LIFE SATISFACTION IN PATIENTS WITH CHRONIC WHIPLASH ASSOCIATED DISORDERS
Y Sterner. I-B Brannholm, J Elert & B Gerdle Department of Rehabilitation Medicine, University of Umea, S-901 85 Umea, Department of Rehabilitation Medicine, Faculty of Health Sciences, S-581 85 Linkoping, Sweden

Aim: to compare aspects of disability (activity preferences and sick leave) and aspects of life satisfaction in a patient group with chronic whiplash associated disorders (WAD) and a healthy group of subjects (C-group).

Material and Methods: The WAD group: 32 consecutive patients (22 females and 10 males), referred to the department of Rehabilitation Medicine at a University hospital. The C-group: 28 men and 27 women who were clinically healthy and randomly recruited from the official census lists. All subjects answered a questionnaire (symptoms, activity preferences, sick leave and an instrument of satisfaction with life).

Results: Satisfaction with life as a whole, physical and psychological health and levels of activity preferences were generally significantly lower in the WAD-group. Significantly higher prevalences of neuropsychological symptoms were noted in the WAD group. Both directly pain related symptoms and neuropsychological symptoms correlated significantly with aspects of disability and life satisfaction.

Conclusions: Chronic WAD can not be viewed only as a neck pain problem. When planning rehabilitation it appears important to have a broader perspective including also categories such as disability and life satisfaction together with coping strategies.

ACUTE PHASE REACTANTS IN RELATION TO SEROTONIN AND JOINT PAIN IN PATIENTS WITH RHEUMATOID ARTHRITIS
Sigvard Kopp. Per Alstergren, Dept Clinical Oral Physiology, Karolinska Institutet, Stockholm, Sweden.

Aim of investigation: To investigate the relationship between erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), serotonin (5-HT) and joint pain in patients with rheumatoid arthritis (RA).

Patients and Methods: Twenty-six patients with seropositive (RF+) and 24 with seronegative (RF-) RA were investigated for general joint and temporomandibular Joint (TMJ) pain by a visual analogue scale as well as for tenderness to digital palpation (TDP) and pressure pain threshold (PPT) over the TMJ and on the glabella. Venous blood samples were taken for ESR, CRP and plasma/serum level of 5-HT (P-5-HT/S-5-HT). A TMJ synovial fluid sample was also taken and analyzed for 5-HT (SF-5-HT).

Results: The ESR, CRP and P-5-HT were all significantly higher in the RF+ than in the RF- group. In the RF+ group both ESR and CRP were correlated to general joint pain. ESR was also correlated to TDP, while CRP also was correlated to S-5-HT and SF-5-HT as well as PPT of the glabella. In the RF- group ESR was correlated to TDP and S-5-HT, while CRP was correlated to PPT of the glabella.

Conclusions: ESR and CRP seem to be associated with general joint pain and local allodynia/ hyperalgesia in RA/RF+ patients, but only with allodynia/ hyperalgesia in RA/RF- patients. CRP is associated with S-5-HT and SF-5-HT in RA/RF+ patients, while ESR is associated with S-5-HT in RA/RF- patients.

Acknowledgements: Supported by Karolinska Institutet and Swedish Dental Society.

Pain in Europe III. EFIC 2000, Nice, France, September 26-29, 2000. Abstracts book, p. 56, 142, 143, 135, 236,242. 243, 244, 249. 251, 257, 262, 268. 272, 275.