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Chronic neck pain is a common cause of disability. The effect of neck trauma on the development of chronic neck pain has been debated. In this population-based study, 8,356 persons (25-79 years) were randomly selected from a geographically well-defined area in northern Sweden. 6000 answered a self-administered questionnaire. We evaluated the data from all participants in the age range 25-64 years, a total of 4,392 persons. 18% reported chronic neck pain, defined as continuous pain of more than 6 months duration. 5% had a history of neck trauma and 13% had no such history. Of all patients with chronic neck pain, 30% had a history of neck injury. We divided all subjects with a chronic neck pain into two groups: those with or without a history of neck trauma. When studying the effect of sociodemographic data, self-perceived health and working conditions, multiple regression analysis showed that the trauma group consisted of significantly more younger men, who were more frequently on sick-leave and that their perceived health was worse than those without a neck injury. We found no significant differences concerning BMI, marital status, educational level, smoking habits, psychosocial work situation on the Karasek questionnaire or physical activity during leisure time or at work. [ABSTRACT FROM AUTHOR]

The two northernmost counties in Sweden form together 1 of the 39 collaborating centers in the World Health Organization (WHO) MONICA (MONItoring of trends and determinants in CArdiovascular disease) project. At the last survey in 1999, we added some questions about cervical spine complaints. Persons randomly selected from the population in a geographically well-defined area completed a self-administered questionnaire. The sample included 8,356 subjects and 6,000 (72%) of them answered. 43% of the population reported neck pain, more women (48%) than men (38%). Women of working age had more neck pain than older ones, a phenomenon not seen among men. Chronic neck pain, defined as continuous pain of more than 6 months' duration, was commoner in women (22%) than men (16%). More than one fourth of the cases with chronic symptoms had a history of neck or head trauma and one third of these had sustained a whiplash type of injury. Thus, all types of neck trauma seem to be associated with chronic neck pain. [ABSTRACT FROM AUTHOR]

Several studies of patients with chronic cervical pain and chronic whiplash syndrome report a high frequency of oculomotor function derangements pointing towards brainstem involvement and/or default sensory input from neck afferents. In light of these reports, it seems important to investigate other patient groups with similar upper cervical spine disorders. In this study, voluntary eye motor performance was evaluated in 11 rheumatoid patients (RA) with upper cervical dislocation and a clearly noticed joint affection of the cervical spine. The results were compared with 6 RA patients without cervical engagement and normal individuals. Nine of the 11 patients with atlanto-axial dislocation showed pronounced oculomotor disturbances of smooth pursuits compared with only minor changes in the control group. The pattern of oculomotor dysfunction in patients with rheumatoid cervical dislocation indicates brainstem involvement, which may be an early sign of brainstem affection/myelopathy. [ABSTRACT FROM AUTHOR]

Extremely low field magnetic resonance imaging (MRI) was evaluated in 16 patients with bone and soft tissue tumors, both benign and malignant. Twelve of the lesions were located in the lower extremity, 2 in the gluteal and 2 in the shoulder region. The findings were compared to the results of computed tomography (CT). Low signal-to-noise ratio and poor spatial resolution result in an image quality which is inferior to that obtained with MR imaging at higher field strengths. In spite of this, the diagnostic information seems to be at least comparable to that obtained from CT. [ABSTRACT FROM AUTHOR]

Background: Type 1 diabetic patients and non-diabetic patients were referred for evaluation for chronic exertional compartment syndrome (CECS) based on clinical examination and complaints of activity-related leg pain in the region of the tibialis anterior muscle. Previous studies using near-infrared spectroscopy (NIRS) showed greater deoxygenation during exercise for CECS patients versus healthy controls; however, this comparison has not been done for diabetic CECS patients., Methods: We used NIRS to test for differences in oxygenation kinetics for Type 1 diabetic patients diagnosed with (CECS-diabetics, n = 9) versus diabetic patients without (CON-diabetics, n = 10) leg anterior chronic exertional compartment syndrome. Comparisons were also made between non-diabetic CECS patients (n = 11) and healthy controls (CON, n = 10). The experimental protocol consisted of thigh arterial cuff occlusion (AO, 1-minute duration), and treadmill running to reproduce symptoms. NIRS variables generated were resting StO2%, and oxygen recovery following AO. Also, during and following treadmill running the magnitude of deoxygenation and oxygen recovery, respectively, were determined., Results: There was no difference in resting StO2% between CECS-diabetics (78.2±12.6%) vs. CON-diabetics (69.1±20.8%), or between CECS (69.3±16.2) vs. CON (75.9±11.2%). However, oxygen recovery following AO was significantly slower for CECS (1.8±0.8%/sec) vs. CON (3.8±1.7%/sec) (P = 0.002); these data were not different between the diabetic groups. StO2% during exercise was lower (greater deoxygenation) for CECS-diabetics (6.3±8.6%) vs. CON-diabetics (40.4±22.0%), and for CECS (11.3±16.8%) vs. CON (34.1±21.2%) (P<0.05 for both). The rate of oxygen recovery post exercise was faster for CECS-diabetics (3.5±2.6%/sec) vs. CON-diabetics (1.4±0.8%/sec) (P = 0.04), and there was a tendency of difference for CECS (3.1±1.4%/sec) vs. CON (1.9±1.3%/sec) (P = 0.05)., Conclusion: The greater deoxygenation during treadmill running for the CECS-diabetics group (vs. CON-diabetics) is in line with previous studies (and with the present study) that compared non-diabetic CECS patients with healthy controls. Our findings could suggest that NIRS may be useful as a diagnostic tool for assessing Type 1 diabetic patients suspected of CECS.

Background and Purpose: Intermittent claudication in diabetes mellitus is commonly associated with arterial disease but may occur without obvious signs of peripheral circulatory impairment. We investigated whether this could be due to chronic exertional compartment syndrome (CECS)., Patients and Methods: We report on 17 patients (3 men), mean age 39 (18-72) years, with diabetes mellitus--12 of which were type 1--and leg pain during walking (which was relieved at rest), without clinical signs of peripheral arterial disease. The duration of diabetes was 22 (1-41) years and 12 patients had peripheral neuropathy, retinopathy, or nephropathy. The leg muscles were tender and firm on palpation. Radiography, scintigraphy, and intramuscular pressure measurements were done during exercises to reproduce their symptoms., Results: 16 of the 17 patients were diagnosed as having CECS. The intramuscular pressures in leg compartments were statistically significantly higher in diabetics than in physically active non-diabetics with CECS (p < 0.05). 15 of the 16 diabetics with CECS were treated with fasciotomy. At surgery, the fascia was whitish, thickened, and had a rubber-like consistency. After 1 year, 9 patients rated themselves as excellent or good in 15 of the 18 treated compartments. The walking time until stop due to leg pain increased after surgery from less than 10 min to unlimited time in 8 of 9 patients who were followed up., Interpretation: Intermittent claudication in diabetics may be caused by CECS of the leg. The intramuscular pressures were considerably elevated in diabetics. One pathomechanism may be fascial thickening. The results after fasciotomy are good, and the increased pain-free walking time is especially beneficial for diabetics.

Background: Chronic exertional compartment syndrome is most often reported in young and physically active people., Patients and Methods: We studied 73 consecutive patients (mean age 39 (16-77) years, 45 women) with a history of exercise-induced pain and suspicion of chronic exertional compartment syndrome (CECS) of the lower leg--clinically, radiographically and with intramuscular pressure measurements., Results: Intramuscular pressure increased with reproduction of symptoms and fulfilled the criteria for diagnosis of CECS in 36 patients (mean age 36 (16-65) years, 22 women), with engagement of 66 anterior, 2 lateral and 7 posterior muscle compartments in 72 legs. The patients with CECS of the lower leg were divided into 4 etiological groups: 18 with overuse, 10 with earlier trauma, 4 insulin-treated diabetics, and 4 others. Two-thirds of the patients had pain during walking. The outcome after fasciotomy was excellent or good in 41/57 of the legs., Interpretation: CECS of the lower leg probably has a multifactorial etiology and is more common in sedentary individuals than has been recognized previously. Fasciotomy appears to be beneficial in these cases also.

A cross-sectional study to investigate regional cerebral blood flow (rCBF) in patients with chronic whiplash syndrome and chronic neck pain patients without previous history of trauma along with a healthy control group. Chronic neck pain is a common disorder and a history of cervical spine injury including whiplash trauma constitute a risk factor for persistent neck pain. The aetiology of the late whiplash syndrome is unknown with no specific diagnostic criteria based on imaging, physiological, or psychological examination. Earlier studies indicate a parieto-occipital hypoperfusion but it is unclear if the hypoperfusion represents a response to chronic pain. The rCBF was monitored in 45 patients with chronic neck pain: 27 cases with chronic whiplash syndrome and 18 age and gender matched cases with non-traumatic chronic neck pain. The rCBF was estimated with single-photon emission computed tomography (SPECT) using technetium-99m hexamethylpropylene amine oxime (HMPAO). The non-traumatic patients displayed rCBF changes in comparison with the whiplash group and the healthy control group. These changes included rCBF decreases in a right temporal region close to hippocampus, and increased rCBF in left insula. The whiplash group displayed no significant differences in rCBF in comparison with the healthy controls. The present study suggests different pain mechanisms in patients with chronic neck pain of non-traumatic origin compared to those with chronic neck pain due to a whiplash trauma.

Background: Congenital insensitivity to pain is a rare hereditary sensory neuropathy., Patients: We present 6 patients from a family with a mutation in the nerve growth factor beta gene (NGFB)., Results: 3 patients were homozygous with a mutilating arthropathy starting early in life, and 3 patients were presumably heterozygous with a milder course starting in adulthood. All patients had normal mental abilities. In addition to absence of deep pain, the patients had impaired temperature sensation, but no autonomic deficiency. Sural nerve biopsies showed a moderate loss of A-delta fibres and a severe reduction in C fibers. Clinically, the disorder most often affected the lower extremities, with an insidious progressive joint swelling or a painless fracture, but the spine could also be involved with gross and unstable spondylolisthesis. Fracture healing was uneventful, but the arthropathy was progressive, eventually resulting in gross deformity and instability. When treating patients with congenital disorders such as this one, it is important to consider the slowly progressive nature of the disorder, and the orthopedic operations should therefore be planned from a long-term standpoint. Arthrodesis, limb lengthening and spinal decompression or fusion are the only elective procedures that seem reasonable. Fitting of orthosis for joint protection is also demanding. To delay the development of neuropathic arthropathy, patient education is essential but difficult in the very young., Interpretation: The different expression between homo- and heterozygous subjects and the central role of nerve growth factor make this disease an interesting model system for studies of disease mechanisms and the molecular background to pain.

Background: It is unclear whether the prevalence of chronic low back pain is higher in chronic whiplash patients than in the general population. In a population-based study, we evaluated the prevalence of chronic low back pain in individuals with chronic neck pain of traumatic and non-traumatic origin, with special emphasis on whiplash injury., Subjects and Methods: Additional questions concerning the patient's experience of neck and low back pain were added to the questionnaire of the MONICA health survey. 4,415 subjects aged 25-64 years were randomly selected from a geographically well-defined area in northern Sweden., Results: The prevalences of chronic low back pain and chronic neck pain were 16% and 17%, respectively. 51% of subjects had both back and neck pain. Of the patients with neck pain, one quarter had a history of neck injury, which was related to whiplash injury in almost one-half of the cases. The prevalence of chronic low back pain in individuals with chronic non-traumatic neck pain was 53%, and it was 48% in those with chronic neck pain and a history of neck trauma. There was no difference in the prevalence of chronic low back pain between whiplash injury and other types of neck trauma. Confounding factors such as sex, age, marital status, BMI, smoking status and level of education were not significantly different between traumatic and non-traumatic groups., Interpretation: Independently of traumatic or non-traumatic origin of the symptoms, the prevalence of chronic low back pain is 3 times higher in individuals with chronic neck pain than in the general population. Causes other than a history of neck trauma, such as chronic muskuloskeletal pain syndromes, may be important in evaluation of these cases.

We measured the neuropsychological functioning in 42 patients with chronic neck pain, 21 with a whiplash trauma and 21 without previous trauma. Subjectively, the whiplash group was more forgetful and had more concentration difficulties compared with the non-traumatic group. The neuropsychological tests did not reveal any differences between the two groups and a reference group of healthy individuals. Thus, chronic neck pain did not seem to interfere with neuropsychological functioning. The personality traits assessed with MMPI-2 in our 42 patients with chronic neck pain differed significantly from the normals on several scales. We also found that the whiplash group had more divergent test results than the non-traumatic group on the MMPI-2 test. Thus, it seems that the health status in those with chronic neck pain is closely linked to separate personality traits. It is concluded that the subjective complaints and poor performance in patients with chronic neck pain may be associated to somatization and inadequate coping, especially in chronic whiplash patients.

We have studied a large Swedish family with a mutation in the nerve growth factor beta (NGFB) gene causing insensitivity to deep pain without anhidrosis (hereditary sensory and autonomic neuropathy, type V; HSAN V). Painfree joint destruction and fractures were common. Peripheral nerve conduction was normal, but temperature thresholds were increased. Sural nerve biopsies showed a moderate loss of A delta fibers and a severe reduction of C fibers. The three most severely affected cases were all born to consanguineous parents, and were homozygotes for the causal genetic mutation. Treatment of these patients is discussed.

Identification of genes associated with pain insensitivity syndromes can increase the understanding of the pathways involved in pain and contribute to the understanding of how sensory pathways relate to other neurological functions. In this report we describe the mapping and identification of the gene responsible for loss of deep pain perception in a large family from northern Sweden. The loss of pain perception in this family is characterized by impairment in the sensing of deep pain and temperature but with normal mental abilities and with most other neurological responses intact. A severe reduction of unmyelinated nerve fibers and a moderate loss of thin myelinated nerve fibers are observed in the patients. Thus the cases in this study fall into the class of patients with loss of pain perception with underlying peripheral neuropathy. Clinically they best fit into HSAN V. Using a model of recessive inheritance we identified an 8.3 Mb region on chromosome 1p11.2-p13.2 shared by the affected individuals in the family. Analysis of functional candidate genes in the disease critical region revealed a mutation in the coding region of the nerve growth-factor beta (NGFB) gene specific for the disease haplotype. This NGF mutation seems to separate the effects of NGF involved in development of central nervous system functions such as mental abilities, from those involved in peripheral pain pathways. This mutation could therefore potentially provide an important tool to study different roles of NGF, and of pain control.

Clinical examination is the only tool available to assess the extent of the nerve tissue damage after a spinal cord injury, and it is well known that the reliability of classification based on clinical examination is not satisfactory, especially in cases with incomplete motor injuries. There is a need to evaluate new methods in order to improve the possibilities of classifying and prognosticating spinal cord injuries. Methods for assessing central nervous system (CNS) damage using markers in cerebrospinal fluid (CSF) have recently been developed. Previous studies have reported glial fibrillary acidic protein (GFAp) and neurofilament protein (NFL) levels in non-traumatic diseases in the central nervous system. The present study is the first report of GFAp and NFL levels in CSF after trauma to the cervical spine. Six cases with cord damage and pronounced neurological deficit showed significantly increased concentrations of both GFAp and NFL in the CSF. Patients with tetrapareses showed higher values than those with incomplete injuries. Three of the 17 whiplash cases had increased levels of NFL, but normal GFAp. Assessment of nervous tissue markers in CSF will probably improve possibilities to classify and prognosticate spinal cord injuries and also to evaluate pharmacological intervention. The increased levels of NFL in three whiplash cases indicate neural damage in a proportion of the cases with neurological deficit. Neurological examinations are presently the only tools for grading and prognostication of spinal cord injuries. Assessment of nervous tissue markers in CSF makes it possible to quantify the degree of nerve cell damage after different types of cervical spine injury ranging from spinal cord lesions to whiplash injuries.

We performed a prospective study of patients with a whiplash trauma to the cervical spine to describe the incidence of these injuries and to evaluate prognostic factors for disability and recovery. A total of 356 patients were enrolled in the study. All the patients received a comprehensive questionnaire after the injury, and 296 cases responded to the follow-up protocol more than 1 year after the accident. Disability related to the whiplash trauma was used as the outcome variable for the assessment of prognostic factors. The annual incidence of acute whiplash trauma in the catchment area was 4.2 per 1,000 inhabitants and 3.2 per 1,000 for whiplash-associated disorder grades 1-3. Thirty-two percent reported persisting disability at follow-up. The following factors were significantly associated with a poor prognosis: pretraumatic neck pain, low educational level, female gender, and whiplash-associated disorder grades 2-3.

Trigeminal sensory impairment is frequent in whiplash cases. The pathophysiology is unknown. The purpose of the present investigation was to prospectively study the trigeminal sensibility for temperature and vibration and to evaluate their relationship with the clinical symptoms. Thirty-four of 43 patients with whiplash injury were investigated through quantitative sensory tests with a mean of 6 weeks and 71 months after injury. Sensory disturbances over the trigeminal skin area persisted over the years ( r = 0.764. p < 0.000). At follow-up, a significant correlation ( r = 0.614, p < 0.000) was found between the sensory disturbances and the symptoms related to the central nervous system, whereas no significant relationship was found with the musculoskeletal symptoms. Trigeminal sensory impairment can either be explained by dysfunction in the central nervous system or by inhibitory mechanisms secondary to pain.

39 consecutive cases of whiplash injury of the neck were examined clinically and with MRI at a mean of 11 days after trauma. 26 of these showed changes on MRI with disc lesions in 25, 10 of which were classified as disc herniations, and a muscle lesion in 1 case. All had neck pain or headache. 29 cases had neurological deficits, mostly sensibility disturbances. 22 of the 26 cases with pathologic MRI findings had neurological signs, as had 7 of the 10 cases with disc herniation. The relationship between the MRI findings and the clinical symptoms and signs was poor.

20 patients operated on with discectomy and anterior cervical fusion because of chronic symptoms after whiplash injury were examined 4 years after surgery. The commonest indications for surgery were disabling headache and neck pain and radiographically verified disc protrusion. At follow-up, 11 patients had reduced headache and neck pain, while paresthesia and radicular pain were diminished in 9 patients. Based on Robinsson's criteria for the evaluation of surgical results, 2 patients had good, 9 had fair and 9 had poor results.

The rate of complications after anterior dislocation of the shoulder was evaluated in 65 patients aged over 40 years. 36 of 55 cases had electromyographically verified axillary nerve or brachial plexus injury. Rotator-cuff lesion was seen in 24 of the 63 sonographically examined cases. At follow-up in a telephone interview on average 3 years after the injury, 27 of the 57 cases had complaints from their shoulder. The incidence of initial nerve and/or cuff lesions was higher in those with persisting symptoms at follow-up.

We investigated eye motility prospectively in 40 patients with a soft-tissue injury of the cervical spine. The initial oculomotor test, performed within 3 months, was pathologic in 8 patients. The follow-up test in 38 patients, on average 15 months after the accident, remained pathologic in the 8 patients and 5 additional patients had changed from normal to pathologic test results. At follow-up, all the 13 patients with oculomotor dysfunction had persisting symptoms, while 5 of the 25 cases with normal test results still were symptomatic.