Whiplash associated disorders: redefining whiplash and its management.
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Bias↗
Biomedical subjects
T Sand
Publications and source records attributed to T Sand.
Higher levels of antibodies against the psoriasis-associated antigen pso p27 in cerebrospinal fluid from patients with low back pain and sciatica.
STUDY DESIGN: A prospective study comparing the presence of antibodies against the psoriasis-associated antigen pso p27 in pain-free control subjects and patients with low back pain and/or sciatica. OBJECTIVES: To analyze the amount of local inflammation present in human lumbar disc disorders, using anti-pso p27 antibodies in the cerebrospinal fluid as a marker and to analyze whether pain intensity correlates with this marker of inflammation. SUMMARY OF BACKGROUND DATA: Pso p27 is a major antigen in psoriasis that is also present, mostly locally, in other inflammatory disorders, such as sarcoidosis, inflammatory bowel disease, and ankylosing spondylitis, inflammation is also thought to play a major role in the generation of lumbar and radicular pain in degenerative disc disorders. METHODS: Anti-pso p27 antibodies in cerebrospinal fluid were quantified using an indirect enzyme-linked immunosorbent assay with pso p27 obtained from patients with psoriasis for use as an antigen. Fifteen patients with spinal stenosis, 11 patients without myelographic disc herniation, 17 patients with disc herniation, and 24 pain-free patient control subjects were studied. RESULTS: Significantly higher levels of anti-pso p27 antibodies were found in patients with myelographic signs of disc herniation than in with patients with no signs of herniation, patients with spinal stenosis, and control subjects. Patients with no known signs of disc herniation and patients with myelographic signs of spinal stenosis (< 10 mm in diameter) caused by degenerative changes, had higher levels of anti-pso p27 antibodies than did control subjects. However, these differences reached only borderline statistical significance. CONCLUSIONS: The results support those in previous reports, that inflammation probably plays an important role in degenerative disk disorders, particularly in disk herniations. That there was no correlation between pain intensity and anti-pso p27 activity indicates that the antigen is probably not essential in pain generation per se. The results may indicate that pso p27 is expressed secondary to, not as an initiator of, inflammation.
Adult↗
The diversity of seizures related to alcohol use. A study of consecutive patients.
The aim of this study was to investigate the influence of hazardous alcohol drinking on the occurrence of epileptic seizures, the semiology of such seizures, and the extent of the problem. A consecutive sample of 142 acute seizure patients (78 male and 64 female, mean age 46 (16-79) years) was studied. Control groups were 185 consecutive sciatica patients and 254 healthy individuals. Subjects with a hazardous alcohol drinking level were identified by a score >8 in the Alcohol Use Disorders Identification Test (AUDIT). Seizures in AUDIT-positive individuals occurring within 72 h of the last drink were considered to be related to alcohol withdrawal. Generalized or partial onset seizures were classified on the basis of history, electroencephalographic (EEG) and neuroradiological findings. Thirty-five percent of seizure patients were AUDIT-positive, whereas conversely 27% were abstainers. Two-thirds of AUDIT-positive seizure patients met the criteria for withdrawal seizures. Indications of partial onset seizures were found in 25 (51%) of AUDIT-positive patients, all secondarily generalized seizures. Sixty percent of generalized onset seizure patients were AUDIT-positive. In conclusion, seizure patients included significantly more AUDIT-positive subjects, as well as abstainers, than healthy Norwegian controls and consecutive sciatica patients from our hospital. Partial onset seizures are more frequent among hazardous drinkers than hitherto recognized. A generalized onset seizure in adults warrants a high suspicion of alcohol as a provoking factor. Routine screening of acute seizure admissions with the Alcohol Use Disorders Identification Test is recommended.
Adolescent↗
Sensitivity to various stimuli in primary headaches: a questionnaire study.
Questions about discomfort or pain produced by various stimuli (e.g., light, sound, exercise, neck movements) are currently used to differentiate between various primary headache disorders. In order to evaluate the usefulness of differences in sensitivity to physical stimuli in headache diagnosis, the answers to a questionnaire about sensitivity to various stimuli were compared in 68 patients with migraine, 45 with tension-type headache, 46 with cluster headache, and 23 patients with cervicogenic headache, and in 71 controls. Even among controls, a high proportion reported that many of these stimuli could elicit some degree of discomfort or pain. Without headache, migraineurs differed from the other patients with headache and controls mainly in their increased sensitivity to light. With headache, patients with tension-type headache were the least sensitive and migraineurs were the most sensitive to all stimuli, except for stimuli stemming from neck movements, to which patients with cervicogenic headache were most sensitive. Migraineurs also reported the highest degree of sensitivity regarding aggravation and provocation of headache. However, the most striking finding was that all patient groups, cluster headache in particular, became significantly more sensitive with headache than without headache to almost all stimulus categories. This may indicate that these headaches share important pathogenetic mechanisms. The fact that no headache had a very specific sensitivity profile may point to weaknesses of present headache classification systems.
Adult↗
Pain after whiplash: a prospective controlled inception cohort study.
OBJECTIVES: In Lithuania, there is 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 the health service is established. An opportunity therefore exists to study post-traumatic pain without the confounding factors present in western societies. METHODS: In a prospective, controlled inception cohort study, 210 victims of a rear end collision were consecutively identified from the daily records of the Kaunas traffic police. Neck pain and headache were evaluated by mailed questionnaires shortly 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. RESULTS: Initial pain 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. CONCLUSIONS: 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 involvement 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 whiplash syndrome.
Accidents, Traffic↗
[Problems after whiplash injuries are seldom chronic].
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Chronic Disease↗
[Neuralgic amyotrophy or an isolated lesion of the anterior interosseal nerve?].
In this article we describe five patients with acute or subacute weakness of flexor pollicis longus and flexor digitorum profundus. A possible diagnosis of an isolated lesion (entrapment) of the anterior interosseus nerve was considered. However, clinical and neurophysiological findings suggested a diagnosis of neuralgic amyotrophy. Three patients experienced acute shoulder pain at the onset. Sensory loss at the base of the thumb was observed in two patients, and two patients were affected bilaterally. All patients had EMG signs of involvement outside the anterior interosseus nerve innervation area. Low amplitude sensory action potentials were observed in three patients. One patient was operated upon and entrapment was not observed during surgery. Reinnervation was not seen after five months, but was noted in three patients who were investigated 13, 13.5, and 30.5 months after the onset. Thus, the prognosis in this unusual form of neuralgic amyotrophy seems to be rather good, and the length of time before reinnervation supports the theory that the site of the lesion must be located proximally, e.g. in the brachial plexus.
Adult↗
Quantitative EEG during controlled hypoglycaemia in diabetic and non-diabetic children.
We investigated quantitative EEG in 19 diabetic children (mean age 14.2 (SD 1.4) years, mean HbA1c 9.8 (SD 1.2)% and 17 non-diabetic children (14.3 (1.1) years) during and after a gradual reduction in plasma glucose with the glucose clamp technique. The amplitudes of the EEG frequency bands at each glucose level were compared to the registration prior to hypoglycaemia. At plasma glucose approximately 4 mmol l(-1), a small increase in delta (p < 0.05) and theta (p < 0.01) amplitude appeared in the combined diabetic and control group. At approximately 3 mmol l(-1), and at glucose nadir, a further and widespread increase in low-frequency EEG activity was observed. In diabetic and non-diabetic subgroups with similar glucose nadirs, the diabetic children had more delta (p < 0.01) and theta (p < 0.01) activity, and more epileptiform activity (p < 0.05), than the non-diabetic children. In the non-diabetic subjects, but not in the diabetic subjects, the increase in delta and theta activity correlated with a hypoglycaemic symptom score (r = 0.75, p = 0.001 and r = 0.77, p < 0.0005, respectively). In conclusion, EEG changes are detectable already at plasma glucose approximately 4 mmol l(-1) in children. EEG deterioration during hypoglycaemia is more pronounced in diabetic than in non-diabetic children. The increase in cerebral disturbances is not accompanied by an increment in hypoglycaemic symptoms in diabetic children.
Adolescent↗
Headache after whiplash: a historical cohort study outside the medico-legal context.
Headache is frequently reported as a chronic complaint after whiplash traumas. Criteria have been presented, but it has not been validated whether any specific headache type emerges after a trauma with whiplash mechanism. In a questionnaire-based historical cohort design, 202 adult Lithuanian individuals were interviewed 1-3 years after experiencing a rear-end car collision. The questionnaire was designed so that a diagnosis of migraine and tension-type headache in accordance with the International Headache Society criteria could be made. "Possible cervicogenic headache" was diagnosed according to Sjaastad et al.'s minimal criteria. The diagnostic panorama in those with traumas was compared with that of an age- and sex-matched control group. The introductory questions did not reveal differences in headache frequencies between the traumatized and control groups (p = 0.60). The prevalence of migraine and tension-type headache (both episodic and chronic) was also similar. A higher frequency of possible cervicogenic headache was observed in the traumatized group (10 vs 5), but the difference was not statistically significant (p = 0.28). Sixteen patients in the accident group had headache > 15 days per month, 11 of the 16 had similar complaints before the trauma, while 5 had worsened headache as compared to (the recollected headache) before the trauma. None of the patients with possible cervicogenic headache reported increased headache after the accident. Accordingly, the present results obtained outside the medico-legal context do not confirm that a specific headache pattern emerges 1-3 years after a rear-end car collision.
Accidents, Traffic↗
Reliability of cephalic thermal thresholds in healthy subjects.
Reproducibility and normal variation of cephalic warm and cold detection thresholds were investigated in three healthy subject groups. The face, the mastoid process, and the hands were studied. No significant intra-observer test-retest difference (n = 20) was found. Good reliability (intra-class correlation coefficient [ICC] > 0.4) was found for 13 of 14 measurements. A small significant inter-observer difference (n = 20) was found for cold thresholds. Good reliability (ICC > 0.4) was observed for both cold and warm thresholds in most of the test locations (6 of 8). In general, the largest variability was found in the mastoid and frontal lateral regions. Thermal thresholds varied with investigation site in 56 controls (ANOVA, p < 0.0005). No significant gender differences were found for cephalic warm and cold thresholds. Most cold thresholds (4 of 5) but also some warm thresholds (2 of 5) increased with age at the cephalic sites. Our results reveal the frontal medial, the maxillar medial, and lateral regions as the most reliable cephalic test locations. The mastoid region may also be useful for investigating the upper cervical small-fiber function.
Adolescent↗
Thermal sensitivity in unilateral headaches.
Thermal thresholds were measured in the face (first and second trigeminal area), over the mastoid process (C2-3 area), and in the hands in patients with migraine (n=17), cluster headache (n=22), and cervicogenic headache (n=20). Significant symptomatic versus nonsymptomatic side differences were generally not found for any headache group. Cluster headache patients had significantly higher warm thresholds than controls (n=24) for most of the cephalic points. Cervicogenic headache patients had significantly higher warm and cold thresholds than controls (n=56) at several cephalic and noncephalic points. Warm thresholds over the mastoid process on the symptomatic side were higher in cervicogenic headache patients compared to the other groups. In migraine patients, thermal thresholds were similar to those in controls. Thus, we found no evidence of focal or unilateral peripheral somatic nerve dysfunction involving C or A-delta fibers in any of the studied headache groups, although a C2-3 root dysfunction in cervicogenic headache could not be excluded. A bilateral central sensory dysfunction in cluster headache and cervicogenic headache may be hypothesized but a generalized peripheral dysfunction can also explain our results.
Adult↗
Pressure algometry in healthy subjects: inter-examiner variability.
The purpose of this study was to estimate inter-examiner reliability of head and neck algometry. Pain perception thresholds were assessed with a mechanical pressure algometer in 21 healthy individuals. Thresholds were assessed at 13 symmetrical points on each side of the head and neck, at the deltoid muscle and at the median finger. The pressure range of the instrument proved insufficient to study the pain perception threshold on the finger, however. Two different examiners carried out one or two examinations in each subject during one day. The sequence of investigations was varied randomly. The inter-examiner reliability was found to be good, with a mean intra-class correlation coefficient (ICC) of 0.75. Intra-examiner reproducibility was excellent (mean ICC = 0.84). The mean inter-examiner coefficient of variation was 18.7%, while the mean coefficient of repeatability (CR) was 1.60 kg/cm2. In comparison, the mean intra-examiner coefficient of variation was 15% while the mean CR was 1.29 kg/cm2. Statistically significant differences between examiners were found for the frontal point (p < 0.01), while a trend towards lower thresholds in one of the two observers was seen in 10 of the 13 non-significant points. Inter-examiner reliability of side differences was excellent, with CR = 1.23 kg/cm2. In conclusion, manual algometry with a rather inexpensive mechanical device has a good to excellent inter-rater reliability. When studying patients, however, the possible bias introduced by different examiners should be taken into account, both regarding study design and data analysis.
Adult↗
Warm and cold sensory thresholds in patients with unilateral sciatica: C fibers are more severely affected than A-delta fibers.
OBJECTIVES: In order to evaluate if nerve root compression or inflammation is the most important pathogenetic mechanism in lumbar radicular pain, we investigated unmyelinated C-fiber function (warm sensation) and myelinated A-delta fiber function (cold sensation) in patients with unilateral L5 or S1 sciatica. MATERIAL AND METHODS: Forty consecutive patients with clinical and radiological evidence of unilateral L5 (n = 29) or S1 (n = 11) sciatica were studied. The warm and cold sensory thresholds (Somedic thermotest, method of limits) were measured on the anterolateral leg (L5 dermatome) and on the calf (S1 dermatome) on both sides. RESULTS: Warm thresholds were significantly higher on the symptomatic side compared to the non-symptomatic side (8.4+/-3.0 vs 6.2+/-2.5 degrees C, P < 0.0005) in the affected dermatome. In a subgroup with confirmed disk herniation at surgery (32 of the 34 operated), significant differences between the symptomatic and the non-symptomatic side for the affected dermatome, were found for both warm (P < 0.0005) and cold (P = 0.003) thresholds. No threshold difference was seen in patients with disk herniations contained within the outer annulus fibrosis (n = 22) compared to those with non-contained herniations (n = 10). CONCLUSIONS: Patients with unilateral sciatica and L5 or S1 nerve root involvement had increased warm thresholds suggesting impaired C-fiber function. Cold thresholds were significantly elevated in a subgroup with operatively confirmed disk herniation. Because myelinated axons are affected more by compression than unmyelinated ones, our results suggest that nerve root inflammation is more important than compression per se in the generation of sciatic pain.
Adult↗
Neurophysiological and anatomical variability of the greater auricular nerve.
OBJECTIVE: To study the normal variation in greater auricular nerve (GAN) conduction and anatomical course. MATERIALS AND METHODS: GAN nerve conduction was studied in 77 healthy adults while 17 GANs were dissected in 10 cadavers. RESULTS: The largest sensory nerve action potentials (SNAP) were recorded when the stimulator was placed 6 or 7 cm from the external acoustic meatus (EAM). Amplitude decreased significantly with age (P = 0.001). The dissected GANs entered the subcutaneous layer between 55 and 105 mm (median 68 mm) from EAM. The postauricular branch was found in 13 of 17 cases. CONCLUSION: A large variation was observed both anatomically and by way of electrical stimulation. SNAP variation does probably reflect the anatomical variation in GAN course, branching, and terminal distribution. The best sites for stimulation were found 6 and 7 cm from EAM at the posterior sternocleiodomastoid border. The maximal amplitude, right:left amplitude ratio, and distal latency may be useful variables in GAN conduction studies.
Action Potentials↗
Quantitative EEG in acute mountain sickness.
OBJECTIVES: To investigate if the EEG response at moderate altitude may predict a person's tolerance to acute mountain sickness (AMS). MATERIALS AND METHODS: Frequency analysis (QEEG) of tape-recorded ambulatory EEG was performed in 6 climbers during a mountaineering expedition to 7546 m above sea level. The QEEG response in climbers, measured at sea level, at 4500 m, and at 1800 m 1-4 days after maximal altitude exposure, was compared to the change observed during consecutive sea level recordings in 10 control subjects. RESULTS: Three climbers experienced slight (grade 1) AMS symptoms both at 4500 m and at maximal altitude exposure (Group 1). Three other climbers (Group 2) had no symptoms at 4500 m, but they developed AMS (grades 1, 2, or 3) at maximal altitude. Alpha amplitudes were higher at 4500 m in group 1 climbers, while it was lower in group 2 climbers compared to the sea level recording. Significant time x group interactions in ANOVA were found for delta (P = 0.005), theta (P = 0.001) and alpha (P = 0.001) amplitude, indicating that QEEG amplitudes decreased significantly at high altitude in group 2 climbers. CONCLUSION: The QEEG response to moderate hypobaric hypoxia is not uniform, but the direction of QEEG amplitude change, particularly in the alpha band, may possibly predict the risk of developing AMS.
Acute Disease↗
Counterregulatory hormone and symptom responses to hypoglycaemia in diabetic children.
The hormonal responses to, and symptoms of, hypoglycaemia were investigated in 19 diabetic children (mean age 14.2 (SD 1.4) years, mean HbA1c 9.8 (SD 1.2)%) and 16 non-diabetic children (14.4(1.0) years) during a gradual reduction in plasma glucose with the glucose clamp technique. Plasma glucose was reduced from approximately 5.7 to approximately 2.6 mmol l(-1) in the diabetic children and from approximately 5.7 to approximately 2.9 mmol l(-1) in the non-diabetic children over 200 min. The mean glycaemic thresholds for adrenaline, and for autonomic and total symptom score, were similar in the diabetic and non-diabetic groups, and were found at plasma glucose levels between 3.4 and 3.7 mmol l(-1). The mean glucose levels which elicited increase of cortisol, growth hormone, and glucagon were lower (p < 0.01), and the mean incremental responses of adrenaline, cortisol, and glucagon were smaller in the diabetic than in the non-diabetic children. In the diabetic children, a correlation was found between Body Mass Index (BMI) and the hypoglycaemic thresholds for autonomic and total symptom scores (r = 0.64, p < 0.01 and r = 0.72, p = 0.001, respectively). We conclude that counterregulatory hormone responses are attenuated in diabetic as compared to non-diabetic children, whereas recognition of autonomic symptoms is similar in the two groups. Diabetic children with a higher BMI seem to have increased awareness of a declining plasma glucose level.
Adolescent↗
Light-induced discomfort and pain in migraine.
Quantitative thresholds for discomfort and pain with monocular and binocular light stimuli were measured in 67 controls and 67 migraine patients (37 migraine with aura and 30 migraine without aura). Patients were more photophobic during attack than outside attack (p < 0.03), and they were more sensitive to light than controls even between attacks (p < or = 0.0001). We found no differences in light sensitivity between migraine with aura and migraine without aura (p > or = 0.93). Unilateral pain affected light sensitivity on both sides. When asked with a questionnaire, 74% of patients answered that they were sensitive to light outside attack and 100% were sensitive during attack. Pain thresholds were generally lower among sensitive than non-sensitive patients (p = 0.004), indicating some agreement between subjective opinion and objective measurements of photophobia. Photophobia seems to be an intrinsic property of migraineurs. It is increased by migraine pain, but seems to be unrelated to migraine characteristics such as nausea, severity of attacks, pain character and pain laterality.
Adolescent↗