Muscle pain due to injury.

Voluntary muscle is the largest human organ system. The musculotendinous contractual unit sustains posture against gravity and movement against inertia. However, when exposed to single or recurrent episodes of biomechanical overloading, muscle injury may occur. Although chronic muscular injuries and myofascial pain syndromes are commonly diagnosed, they remain poorly understood. Techniques for evaluation of the muscular components of a pain syndrome involve palpation, strength testing, range of motion, and assessment of muscle endplay. Management of acute injuries may necessitate imaging and surgery consultation for lacerations or hemorrhage. Treatment of acute syndromes consists of cryotherapy and reduced activity, whereas chronic syndromes may require multiple therapeutic approaches, applied together or sequentially.

Vertebral artery anomaly with atraumatic dissection causing thromboembolic ischemia: a case report.

STUDY DESIGN: A case report is presented. OBJECTIVES: To illustrate a rare cause of atraumatic vertebral artery dissection resulting from anomalous entry of the vessel at the C3 transverse foramen induced by normal physiologic head and neck motion, and to review vertebral artery anatomy and mechanisms whereby it is vulnerable to pathologic compression. SUMMARY OF BACKGROUND DATA: The vertebral artery usually enters the transverse foramen at C6. Rarely, the artery enters at C5 or C4. Only one prior case with entry at C3 has been reported. That patient experienced recurrent quadriplegia and locked-in syndrome caused by vertebral artery obstruction. A 27-year-old woman with a history of classic migraine experienced neurologic symptoms on three occasions related to physiologic neck and arm movements. Magnetic resonance angiogram was not diagnostic, but standard arteriography demonstrated anomalous vertebral artery entry into the C3 transverse foramen and focal dissection. METHODS: Pertinent literature and the patient's history, physical examination, and radiologic studies were reviewed. RESULTS: Standard cervico-cerebral arteriogram demonstrated focal dissection at C4 and thromboembolic complications in distal vertebral and basilar arteries. Initially, diagnosis by magnetic resonance angiogram was elusive. However, arteriography allowed prompt diagnosis followed by anticoagulation with resolution of neurologic symptoms. CONCLUSIONS: Vertebral artery dissection without trauma is rare, but should be considered when neurologic symptoms accompany physiologic cervical movements. For cases in which vertebrobasilar thromboembolic ischemia is suspected, magnetic resonance angiogram may prove inadequate for demonstrating the causative vascular pathology. Therefore, standard cervico-cerebral arteriography should be performed.

Development of the Neck Pain and Disability Scale. Item analysis, face, and criterion-related validity.

STUDY DESIGN: The development and testing of a new comprehensive measure of neck pain and disability, the Neck Pain and Disability Scale. OBJECTIVES: To provide an initial evaluation of the Neck Pain and Disability Scale's reliability and validity. SUMMARY OF BACKGROUND DATA: Although several measures exist for generalized pain and disability, none is specific for neck pain. More specific measurements should improve assessment of treatments and clinical research aimed at cervical pain syndromes. METHODS: The Neck Pain and Disability Scale was designed using the Million Visual Analogue Scale as a template and consists of 20 items that assess neck pain. In this study, 100 patients with neck pain, 52 patients with lower back and leg pain, and 27 pain-free volunteers were rated by the Neck Pain and Disability Scale. In addition, a subset of the 47 patients with neck pain were rated by several other established psychometric instruments. RESULTS: An item analysis showed a high degree of internal consistency among the 20 items on the Neck Pain and Disability Scale (r = 0.93), and face validity was established by comparing patients who had neck pain as well as lower back and leg pain with a pain-free group. The Neck Pain and Disability Scale scores correlated with the Oswestry Disability Questionnaire, the Pain Disability Index, and psychological measures of depression and neuroticism. CONCLUSIONS: The results suggest a highly reliable instrument for evaluating neck pain with at least four underlying dimensions. Further work to address the predictive validity of this new tool are under way.

Spinal and radicular pain disorders.

Although most acute conditions of the spine are benign and self-limited, the economic costs and disability resulting from these disorders have reached epidemic proportions in industrialized society. Recent scientific research to determine the causes of common spinal disorders, long attributed to structural abnormalities, have now implicated complex biochemical and neurophysiologic processes which may offer insights for future therapy interventions. This article reviews the functional and pathologic anatomy and correlates with current diagnostic and nonoperative management strategies for common mechanical spinal and radicular pain syndromes.

A randomized, double-blind, prospective pilot study of botulinum toxin injection for refractory, unilateral, cervicothoracic, paraspinal, myofascial pain syndrome.

STUDY DESIGN: In a randomized, double-blind study, two dosage strengths of botulinum toxin type A were compared with normal saline injected into symptomatic trigger points in the cervicothoracic paraspinal muscles. OBJECTIVES: To compare the effect of botulinum toxin type A injections with that of normal saline to determine the former's usefulness in the management of neck pain and disability. SUMMARY OF BACKGROUND DATA: The results of several studies have suggested that botulinum toxin type A may reduce pain associated with myofascial pain syndromes. METHODS: Thirty-three participants were divided randomly to receive either 50 or 100 units of botulinum toxin type A, or normal saline. Patients were re-evaluated over a 4-month period by assessment of their pain and disability and pressure algometer readings, and then offered a second injection of 100 units of botulinum toxin type A. RESULTS: All three groups showed significant treatment effects as measured by a decline in the scores on the Neck Pain and Disability Visual Analogue Scale and an increase in the pressure algometer scores. Group differences were apparent only when the authors considered the number of patients who were asymptomatic as a result of the injections. CONCLUSIONS: Although no statistically significant benefit of botulinum toxin type A over placebo was demonstrated in this study, the high incidence of patients who were asymptomatic after a second injection suggests that further research is needed to determine whether higher dosages and sequential injections in a larger cohort might show a botulinum toxin type A effect.

Botulinum toxin A, adjunctive therapy for refractory headaches associated with pericranial muscle tension.

Pericranial muscle tension may contribute to the development of facial discomfort, chronic daily headache, and migraine-type headache. Elimination of pericranial muscle tension may reduce associated myalgia and counteract influences that can trigger secondary headaches which fall within the migraine continuum. Four patients with chronic, predominantly tension-type headaches and associated pericranial muscle tension failed prolonged conventional treatment and, therefore, symptomatic areas were treated with botulinum toxin A. This alleviated myalgia and reduced the severity and frequency of migraine-type headaches with a concomitant reduction in subsequent medical and physical therapy interventions. Judicious use of botulinum toxin A into defined areas of pericranial muscle tension may be useful for reducing primary myalgia and secondary headache.

Therapeutic uses of botulinum toxin.

Botulinum toxin was introduced as a safe and effective treatment for strabismus and other disorders of the extraocular muscles in the early 1980s. Approved by the U.S. Food and Drug Administration for use in the treatment of strabismus, blepharospasm and seventh cranial nerve disorders, botulinum toxin has also been shown to be effective in the treatment of a wide range of disorders associated with involuntary muscle contraction and spasm, including focal dystonia, hemifacial spasm and spasmodic torticollis. Neurologic syndromes associated with excessive muscle contraction or involuntary movement, disturbances of sphincter function and musculoskeletal pain are other conditions that can be successfully treated with botulinum toxin.

Diagnosis and management of low back pain and sciatica.

Acute low back pain with associated sciatica is usually a benign, self-limited disorder. Appropriate medical treatment may include passive forms of physical therapy, including McKenzie exercises, manipulation, medication and therapeutic injections. After pain is controlled, the patient should be taught self-management techniques, including exercises and ergonomic protection of the spine. Evidence is increasing that exercise programs are effective, although the optimal regimen has yet to be defined and may vary from patient to patient. Chronic low back pain is a complex disorder that must be managed aggressively with a multidisciplinary approach that addresses physical, psychologic and socioeconomic aspects of the illness. Self-administered traction, corsets, medications and other treatment methods may prove to be useful adjuncts to an active program of exercise and education that promotes functional restoration.

Nonoperative treatment for low back pain. Rest to restoration.

Pain and disability due to disorders of the lumbar spine are endemic in industrialized society. Nonoperative management of low back pain syndromes is most often successful but is complicated by myriad of unproven treatment options. Recent studies have shown that the natural history favors recovery regardless of the type of treatment. With increasing time from onset of symptoms, therapeutic interventions shift from rest and applied therapies to exercise and physical restoration. This also requires an evolution from passive to active participation by the patient. This article outlines current trends and recommendations for the application of various nonoperative treatment methods as low back pain persists through time.

Episodic catatonia, hypertension, and tachycardia: elevated plasma catecholamines.

We studied autonomic function in a 34-year-old woman who had episodes of catatonia, hypertension, and tachycardia. In one of these episodes, epinephrine and norepinephrine levels were extremely high. Catecholamine clearance was normal. Platelet alpha 2-adrenergic receptors were normal in number and affinity. Results of the phenylephrine infusion test suggested that these episodes were due to central activation of the sympathetic nervous system.