Thoracic outlet syndrome.

It is important to remember the possibility of nonspecific thoracic outlet syndrome (TOS) when treating patients with neck and upper extremity symptoms. There are no specific diagnostic criteria for the syndrome. Diagnosis is based on symptoms, clinical examination and the ruling out of other causes. The first-line option of clinical care is conservative treatment, which in most cases is sufficient for the patient to regain normal functioning. However, some of the most difficult TOS patients need surgical treatment, especially when persistent symptoms have already begun in adolescence, and if compression of neural or vascular structures is thought to result from anatomical structures. Conservative treatment options are essential also for surgically treated patients.

Dynamic kine magnetic resonance imaging in whiplash patients and in age- and sex-matched controls.

The multitude of symptoms following a whiplash injury has given rise to much discussion because of the lack of objective radiological findings. The ligaments that stabilize the upper cervical spine can be injured. Dynamic kine magnetic resonance imaging (dMRI) may reveal the pathological motion patterns caused by injury to these ligaments. To compare the findings and motion patterns in the upper cervical spine, 25 whiplash trauma patients with longstanding pain, limb symptoms and loss of balance indicating a problem at the level of C0-C2, as well as matched healthy controls were imaged using dMRI. Imaging was performed with an Intera 1.5 T (Philips Healthcare, USA) magnet. A physiotherapist performed the bending and rotation of the upper cervical spine for the subjects to ensure that the movements were limited to the C0-C2 level. An oblique coronal T2- and proton density-weighted sequence and a balanced fast field echo axial sequence were used. The movements between C0-C2 and the signal from the alar ligaments were analyzed. Contact of the transverse ligament and the medulla in rotation was seen in two patients. The signal from the alar ligaments was abnormal in 92% of the patients and in 24% of the control subjects (P<0.0001). Abnormal movements at the level of C1-C2 were more common in patients than in controls (56% versus 20%, P=0.028). Whiplash patients with longstanding symptoms had both more abnormal signals from the alar ligaments and more abnormal movements on dMRI at the C0-C2 level than controls.

[Diabolically intense axillary-scapular pain in a colleague]. / Kollegan pirullisen ankara kainalo-lapakipu.

We describe a middle-aged patient, in whom a rare subluxation of the costotransversal joint caused a severe axillary pain. Diagnosis was not achieved by imaging studies or electroneuromyography, but instead simply by palpation. A good treatment outcome was obtained by manipulation.

Psychosocial differences as predictors for recovery from chronic low back pain following manipulation, stabilizing exercises and physician consultation or physician consultation alone.

OBJECTIVE: Three psychosocial profile groups are introduced in the Multidimensional Pain Inventory for chronic pain patients. Patients with the dysfunctional profile have shown a more favourable outcome after multidisciplinary treatments, due to the suggested effects of specific psychosocial treatment elements. In this study we explored, among patients with chronic low back pain, whether the Multidimensional Pain Inventory patient profile groups might respond differently to treatment without planned psychosocial elements. METHODS: Of 204 voluntarily recruited patients with chronic low back pain, 102 were randomized to a combined manipulation, exercise and physician consultation group (called the combination group) and 102 to a consultation-alone group. RESULTS: Although all subjects showed improvement during follow-up both on the Oswestry index and the Visual Analogue Scale, the dysfunctional profile patients in the combination group improved the most. Their high pre-treatment ratings on Oswestry and Visual Analogue-scales fell at the 5- and 12-month follow-ups to the same level as those of the adaptive copers or interpersonally distressed patients, and they were on a significantly lower level than the dysfunctional profile patients in consultation group during follow-up. All dysfunctional profile patients also showed a decrease in affective distress, equally in combination and consultation groups. CONCLUSION: We suggest that dysfunctional profile patients are more sensitive to respond even to treatment without any specific psychosocial elements. This should be considered when evaluating any treatment effects. Among dysfunctional profile patients, pain-related anxiety and decreased acceptance of pain may contribute to their sensitivity to treatment.

Predictive factors for 1-year outcome of chronic low back pain following manipulation, stabilizing exercises, and physician consultation or physician consultation alone.

OBJECTIVES: To examine the relative influences of sociodemographic and episode-specific factors on change in low back pain intensity and self-rated disability. METHODS: Of 204 patients with chronic low back pain, 102 were randomized to a combined manipulation, exercise and physician consultation group and 102 to a consultation-alone group. These groups were each divided into 2 clusters based on change in both pain intensity and self-rated disability at 1 year. The first cluster included patients whose symptoms clearly decreased, and the second those whose trouble persisted. Association between sociodemographic and episode-specific factors and poor recovery from low back pain and disability were evaluated by univariate and multivariate analysis. RESULTS: Severe affective distress (OR 3.81; 95% CI 1.3-10.8) predicted poor response to the manipulative treatment. Over a 25-day sick leave during previous year (19.64; 3.8-102.5), poor life control (9.40; 1.9-47.0), and generalized somatic symptoms (3.18; 0.9-11.6) were the risk factors for not benefiting from the informative approach. CONCLUSIONS: Psychosocial differences seem to be important determinants for treatment outcomes, and should be the focus of future studies.

Whiplash injuries in Finland--the possibility of some sociodemographic and psychosocial factors to predict the outcome after one year.

PURPOSE: The aim of our study was to evaluate if there was any relation between the change experienced in the condition of health or the length of the reported sick leaves after one year of whiplash injury and different sociodemographic and psychosocial factors. METHOD: Our study design is a prospective 1-year-follow-up study. The material was collected in the year 1998 from neck injuries that had been caused by traffic accidents. The insurance companies sent a notice of the accident with medical certificate to the research team. After this we sent questionnaires to the injured and after one year of the accident a new inquiry was done. One hundred and eighty-two persons returned the 1-year-follow-up questionnaire which formed the material of this study. RESULTS: The persons who had the lowest basic education and people over 60 years of age had more health problems after one year of the accident. The other sociodemographic and psychosocial factors had only limited prognostic value when we evaluated the experienced change of health one year after the whiplash injury. Only 71 persons reported that they had been on sick leave because of the whiplash injury and of them only 21 reported sick leave over 1 month. CONCLUSIONS: Several sociodemographic and psychosocial factors can have relation to the deterioration of health experienced after whiplash injury but in this prospective study they proved to have only limited prognostic value in the long term symptoms with the exception of the education.

Comparison of radiologic signs and clinical symptoms of spinal stenosis.

STUDY DESIGN: Clinical findings of spinal stenosis were compared to graded radiologic findings of dural sac narrowing. OBJECTIVES: To examine the changes of the dural sac area of the lumbar spine on computerized tomography (CT) performed without and with axial loading, and study the correlations between the radiologic findings and clinical symptoms suggestive of spinal stenosis. SUMMARY OF BACKGROUND DATA: Although several studies have been performed regarding the advantage of an external compression device in lumbar CT, to our knowledge, none of these studies have correlated radiologic findings with clinical symptoms. METHODS: The cross-sectional areas of the dural sac at the 3 lowest lumbar intravenous spaces, measured by CT both without and with external compression, were correlated to the clinical symptoms suggestive of spinal stenosis in 117 patients and 351 intervertebral levels. RESULTS: No statistically significant correlation between the severity of the clinical symptoms of spinal stenosis and dural cross-sectional areas was found. Neither did the use of an external compression device improve the correlation. CONCLUSION: Although an external compression simulates the dynamic condition in the back during standing position, it does not eliminate the need to compare the radiologic findings with the clinical symptoms of patients examined because of a suspected narrowing of the spinal canal.

The treatment of disc-herniation-induced sciatica with infliximab: one-year follow-up results of FIRST II, a randomized controlled trial.

STUDY DESIGN: A randomized controlled trial. OBJECTIVES: To evaluate the long-term efficacy of infliximab, a monoclonal antibody against tumor necrosis factor alpha (TNF-alpha), in patients with acute/subacute sciatica secondary to herniated disc. SUMMARY OF BACKGROUND DATA: The results of experimental studies and our open-label trial support the use of infliximab in sciatica. Here we report the 1-year results of a randomized controlled trial (FIRST II, Finnish Infliximab Related STudy) evaluating the efficacy and safety of a single infusion of infliximab for sciatic pain. METHODS: Inclusion criteria were unilateral sciatic pain with a disc herniation concordant with the symptoms and signs of radicular pain. Patients had to be candidates for discectomy. Criteria for discectomy included (in addition to a symptomatic disc herniation on MRI) neural entrapment (straight leg raising [SLR] < or =60 degrees ) with either a short-term (2-4 weeks) severe or long-term (4-12 weeks) moderate leg pain. Forty patients were allocated to a single intravenous infusion of either infliximab 5 mg/kg or placebo. Differences in the clinical examination parameters (straight leg raise [SLR], muscle strength, sensory defects, tendon reflexes), patient-reported symptoms (leg and back pain using a visual analog scale [VAS], Oswestry disability, quality-of-life [RAND-36]), sick leaves, number of discectomies, and adverse effects between the two treatment groups over the 1-year follow-up were compared using Mann-Whitney U test or Student's t test, repeated-measures analysis, or Cox proportional hazards model. Logistic regression was used to assess the predictors of good response. RESULTS: Sixty-seven percent of patients in the infliximab group reported no pain at 52 weeks compared with 63% in the control group (P = 0.72). Similar efficacy was observed between treatment groups for other outcomes. Eight patients in each group required surgery. Three nonserious adverse reactions were encountered in the infliximab group. The response (irrespective of the treatment) was significantly better with shorter symptom duration and less SLR restriction at baseline. Patients in the infliximab group appeared to especially benefit in cases of a L4-L5 (or L3-L4) herniation and if a Modic change was colocalized at the symptomatic level. CONCLUSIONS: Although the long-term results of this randomized trial do not support the use of infliximab compared with placebo for lumbar radicular pain in patients with disc herniation-induced sciatica, further study in a subgroup of patients with L4-L5 or L3-L4 herniations, especially in the presence of Modic changes, appears to be warranted.

Cost-effectiveness of combined manipulation, stabilizing exercises, and physician consultation compared to physician consultation alone for chronic low back pain: a prospective randomized trial with 2-year follow-up.

STUDY DESIGN: A prospective, randomized controlled trial. OBJECTIVE: To examine long-term effects and costs of combined manipulative treatment, stabilizing exercises, and physician consultation compared with physician consultation alone for chronic low back pain (cLBP). SUMMARY OF BACKGROUND DATA: An obvious gap exists in knowledge concerning long-term efficacy and cost-effectiveness of manipulative treatment methods. METHODS: Of 204 patients with cLBP whose Oswestry Disability Index (ODI) was at least 16%, 102 were randomized into a combined manipulative treatment, exercise, and physician consultation group (i.e., a combination group), and 102 to a consultation alone group. All patients were clinically examined, informed about their back pain, and encouraged to stay active and exercise according to specific instructions based on clinical evaluation. Treatment included 4 sessions of manual therapy and stabilizing exercises aimed at correcting the lumbopelvic rhythm. Questionnaires inquired about pain (visual analog scale (VAS)), disability (ODI), health-related quality of life (15D Quality of Life Instrument), satisfaction with care, and costs. RESULTS: Significant improvement occurred in both groups on every self-rated outcome measurement. Within 2 years, the combination group showed only a slightly more significant reduction in VAS (P = 0.01, analysis of variance) but clearly higher patient satisfaction (P = 0.001, Pearson chi2) as compared to the consultation group. Incremental analysis showed that for combined group compared to consultation group, a one-point change in VAS scale cost $512. CONCLUSIONS: Physician consultation alone was more cost-effective for both health care use and work absenteeism, and led to equal improvement in disability and health-related quality of life. It seems obvious that encouraging information and advice are major elements for the treatment of patients with cLBP.

The treatment of disc herniation-induced sciatica with infliximab: results of a randomized, controlled, 3-month follow-up study.

STUDY DESIGN: A randomized controlled trial. OBJECTIVES: To evaluate the efficacy of infliximab, a monoclonal antibody against tumor necrosis factor (TNF)-alpha in a randomized controlled setting. SUMMARY OF BACKGROUND DATA: Recently, we obtained encouraging results in an open-label study of infliximab in patients with disc herniation-induced sciatica. Furthermore, the results of experimental studies support the use of infliximab in sciatica. Therefore, we initiated a randomized, controlled trial (FIRST II, Finnish Infliximab Related STudy) to confirm the efficacy of a single infusion of infliximab for sciatic pain. METHODS: Inclusion criteria were unilateral moderate to severe sciatic pain with an MRI-confirmed disc herniation concordant with the symptoms and signs of radicular pain. Patients had to be candidates for discectomy, as evaluated by an independent orthopedic surgeon. Forty patients were allocated to a single intravenous infusion of either infliximab 5 mg/kg or placebo. Assessments at baseline and various time points included clinical examination with measurement of straight leg raising restriction; questionnaires related to subjective symptoms (leg and back pain by 100-mm visual analog scale, Oswestry disability); sick leaves; number of discectomies; and adverse effects possibly related to treatment. The primary endpoint was a reduction in leg pain from baseline to 12 weeks, which was analyzed using a Mann-Whitney U test and repeated-measures analysis. RESULTS: A significant reduction in leg pain was observed in both groups, with no significant difference between treatment regimens. Similar efficacy was observed between treatment groups for secondary endpoints. Seven patients in each group required surgery. No adverse effects related to treatment were encountered. CONCLUSIONS: The results of this randomized trial do not support the use of infliximab for lumbar radicular pain in patients with disc herniation-induced sciatica.

The possibility to use simple validated questionnaires to predict long-term health problems after whiplash injury.

STUDY DESIGN: A prospective follow-up study. OBJECTIVES: To evaluate the relation of the state of health before the accident and the significance of the symptoms reported soon after the injury to the situation 3 years after the injury. To evaluate the possibility of using simple validated questionnaires to predict long-term health problems after the injury. SUMMARY OF BACKGROUND DATA: A whiplash injury is generally benign in its natural course. However, some of the patients have diverse and prolonged symptoms. Although several prognostic factors have been suggested for the poor recovery, in most cases the factors leading to prolonged disability remain unclear. METHODS: In collaboration with traffic insurance companies, we gathered information of neck injuries that occurred in traffic accidents in Finland in 1998. After the insurance company received a notification of a neck injury and consent from the injured party to participate in the study, they sent the information to the research team. The first inquiry was sent to the patients as soon as possible. One- and three-year follow-up questionnaires were posted to those who responded to the first inquiry. A total of 144 persons returned the 3-year follow-up questionnaires and form the material of this study. RESULTS A poor state of health or frequent neck pain or headache before the accident did not have any significant relation to the poor outcome 3 years after the accident. The extent of neck pain and lower back pain reported soon after the accident was significantly associated to a poor outcome in the follow-up. The Neck Disability Index questionnaire was significantly related to the poor outcome after 3 years. CONCLUSIONS: The subjective experience of a notably decreased level of activity because of the neck pain when supplemented by the enhanced score of Neck Disability Index questionnaire predicts well poor outcome in long-term follow-up and can be used as a tool to identify persons who are at risk to suffer long-term health problems after whiplash injury.

Whiplash injuries in Finland: the situation 3 years later.

The aim of this study was to define the influence of whiplash injuries on the perceived condition of health 3 years after injury. We evaluated remaining symptoms and the use of health services. Insurance companies provided reports and medical certificates from traffic accidents in Finland in 1998, for those injured who had agreed to take part in the study. Participants in the 1-year follow-up study answered a self-report questionnaire. Three years after the whiplash-causing accident, 11.8% of participants reported that injury symptoms had caused their health to deteriorate significantly as compared with before the accident. Neck pain was the most common single symptom, reported by 14.6% of respondents. The severity of the initial symptoms according to the WAD classification is reflected in the subject's self-perception of health after 3 years. A remarkable 10-17% of respondents still used health services regularly because of the symptoms. Although some of the injured had improved in the long term, some reported that their health condition was worse after 3 years than at the 1-year follow-up. The percentage of respondents reporting a significant health deterioration remains unchanged 3 years after the whiplash injury. These findings illuminate the importance of early recognition of risk factors for long-term disability and the primary treatment and rehabilitation procedures.

A randomized trial of combined manipulation, stabilizing exercises, and physician consultation compared to physician consultation alone for chronic low back pain.

STUDY DESIGN: A prospective randomized controlled trial. OBJECTIVES: To examine the effectiveness of combined manipulative treatment, stabilizing exercises, and physician consultation compared with physician consultation alone for chronic low back pain. SUMMARY OF BACKGROUND DATA: Strong evidence exists that manual therapy provides more effective short-term pain relief than does placebo treatment in the management of chronic low back pain. The evidence for long-term effect is lacking. METHODS: Two hundred four chronic low back pain patients, whose Oswestry disability index was at least 16%, were randomly assigned to either a manipulative-treatment group or a consultation group. All were clinically examined, informed about their back pain, provided with an educational booklet, and were given specific instructions based on the clinical evaluation. The treatment included four sessions of manipulation and stabilizing exercises aiming to correct the lumbopelvic rhythm. Questionnaires inquired about pain intensity, self-rated disability, mental depression, health-related quality of life, health care costs, and production costs. RESULTS: At the baseline, the groups were comparable, except for the percentage of employees (P = 0.01). At the 5- and 12-month follow-ups, the manipulative-treatment group showed more significant reductions in pain intensity (P < 0.001) and in self-rated disability (P = 0.002) than the consultation group. However, we detected no significant difference between the groups in health-related quality of life or in costs. CONCLUSIONS: The manipulative treatment with stabilizing exercises was more effective in reducing pain intensity and disability than the physician consultation alone. The present study showed that short, specific treatment programs with proper patient information may alter the course of chronic low back pain.

Efficacy of infliximab for disc herniation-induced sciatica: one-year follow-up.

STUDY DESIGN: An open-label trial. OBJECTIVES: To test the long-term efficacy of infliximab, a monoclonal antibody against tumor necrosis factor-alpha (TNF-alpha), in disc herniation-induced sciatica. SUMMARY OF BACKGROUND DATA: Our recent trial indicated that a single infusion of 3 mg/weight-kg of infliximab produced a rapid curative effect in disc herniation-induced sciatica. Here, we describe the 1-year effect of a 3 mg/kg of infliximab in these 10 patients and our experience with a lower dose of 1 mg/kg of infliximab for the same indication in 2 additional patients. METHODS: Patients with severe sciatica were treated with a single infusion of infliximab, 3 mg/weight-kg in 10 patients and 1 mg/kg in 2 patients, intravenously over 2 hours. The outcomes (leg and back pain on a 100-mm visual scale, Oswestry disability, clinical signs) were assessed at 1 week, 2 weeks, 1 month, 3 months, 6 months, and 1 year after the infusion. The outcomes with 3 mg/kg of infliximab were compared to 62 patients who received periradicular saline for sciatica in a previous trial. The resorption rate of disc herniations from baseline to 1 year was compared between infliximab and control groups. RESULTS: The response to 1 mg/kg of infliximab for leg pain was good only in 1 of the 2 patients treated, whereas the response to 3 mg/kg of infliximab for leg pain was sustained in most patients over the 1-year follow-up. The 1-year response significantly favored 3 mg/kg of infliximab over periradicular saline in leg pain (P = 0.005) and disability (P = 0.003). Neurologic abnormalities normalized more comprehensively in the infliximab group (P = 0.001). Reduction in disc herniation volume did not differ between the infliximab-treated patients and controls. CONCLUSIONS: The results showed that the beneficial effect of a single infusion of 3 mg/kg of infliximab for herniation-induced sciatica is sustained in most patients over a 1-year follow-up period. Furthermore, infliximab does not seem to interfere with the spontaneous resorption of disc herniations.

Tumor necrosis factor-alpha monoclonal antibody, infliximab, used to manage severe sciatica.

STUDY DESIGN: An open-label study was conducted. OBJECTIVE: To evaluate the efficacy and safety of infliximab, a monoclonal chimeric antibody, against tumor necrosis factor-alpha (TNFalpha) for the treatment of severe sciatica. SUMMARY OF BACKGROUND DATA: Evidence from animal studies indicates that TNFalpha plays a role in the pathophysiology of sciatica. Anti-TNFalpha therapy has not been previously evaluated in sciatic patients. METHODS: In this study, 10 patients with disc herniation-induced severe sciatica received infliximab (Remicade 3 mg/kg) intravenously over 2 hours. The outcome was assessed at 1 hour, 1 week, 2 weeks, 1 month, and 3 months after the infusion and compared to historical control subjects consisting of 62 patients who received saline in a trial of periradicular infiltration for sciatica. Leg pain was the primary outcome, with more than a 75% decrease from the baseline score constituting a painless state. Fisher's exact test and repeated measures analysis of variance were used for statistical analysis. RESULTS: At 1 hour after the infusion, leg pain had decreased by 50%. At 2 weeks, 60% of the patients in the infliximab group were painless, as compared with 16% of the control patients (P = 0.006). The difference was sustained at 3 months (90% vs 46%; P = 0.014). Infliximab was superior over the whole follow-up period in terms of leg pain (P = 0.003) and back-related disability (P = 0.004). At 1 month, every patient in the infliximab group had returned to work, whereas 38% of the control subjects still were on sick leave (P = 0.02). None of the patients treated with infliximab underwent surgery during the follow-up period. No immediate or delayed adverse drug reactions and no adverse effects related to medication were observed. CONCLUSIONS: Anti-TNFalpha therapy is a promising treatment option for sciatica. There is an urgent need for a randomized controlled trial to evaluate whether thesepromising early results can be confirmed.