Effects of acupuncture, cervical manipulation and NSAID therapy on dizziness and impaired head repositioning of suspected cervical origin: a pilot study. Long-term results of cervical epidural steroid injection with and without morphine in chronic cervical radicular pain. Treatment of myofascial pain. C2/C3 nerve blocks and greater occipital nerve block in cervicogenic headache treatment. A comparative study of diazepam and acupuncture in patients with osteoarthritis pain: a placebo controlled study. [Comparison of eterilate and acetylsalicylic acid in the treatment of cervicoarthrosis: double blind test]. A randomized, double-blind, prospective pilot study of botulinum toxin injection for refractory, unilateral, cervicothoracic, paraspinal, myofascial pain syndrome. [A prospective double blind study of cervical nerve infiltration with isotonic saline and local anaesthetic]. Lidocaine injection versus dry needling to myofascial trigger point. The importance of the local twitch response. Lack of effect of intraarticular corticosteroids for chronic pain in the cervical zygapophyseal joints. Sphenopalatine ganglion block for the treatment of myofascial pain of the head, neck, and shoulders. [Ibuprofen in the treatment of the cervicocranial syndrome in combination with manipulative therapy]. Treatment of whiplash associated neck pain [corrected] with botulinum toxin-A: a pilot study. Evidence against trigger point injection technique for the treatment of cervicothoracic myofascial pain with botulinum toxin type A. Cervical epidural steroid injection for cervicobrachialgia. Chronic spinal pain syndromes: a clinical pilot trial comparing acupuncture, a nonsteroidal anti-inflammatory drug, and spinal manipulation. High-dose methylprednisolone prevents extensive sick leave after whiplash injury. A prospective, randomized, double-blind study. Botulinum toxin A for the treatment of chronic neck pain. [Therapy of cervico-brachialgia. Controlled clinical comparison of a high-dose combination of neurotropic vitamins with an analgesic]. Comparison of lidocaine injection, botulinum toxin injection, and dry needling to trigger points in myofascial pain syndrome. Analgesic effectiveness of subcutaneous carbon-dioxide insufflations as an adjunct treatment in patients with non-specific neck or low back pain. Reflex cervical muscle spasm: treatment by diazepam, phenobarbital or placebo. Intramuscular ketorolac versus osteopathic manipulative treatment in the management of acute neck pain in the emergency department: a randomized clinical trial. Comparative study of high bio-availability glaphenine and paracetamol in cervical and lumbar arthrosis.
In a single-subject experiment undertaken on 14 consecutive patients, the effects of acupuncture, cervical manipulation, no therapy, and NSAID-percutan application on kinesthetic sensibility, dizziness/vertigo and pain were studied in patients with dizziness/vertigo of suspected cervical origin. The ability to perceive position of the head with respect to the trunk was studied. The effects of different forms of therapy-and none-on dizziness and neck pain were compared, using a 100 mm visual analogue scale (VAS). Active head relocation by subjects with dizziness was significantly less precise than in the control group. Manipulation was the only treatment to diminish the duration of dizziness/vertigo complaints during the past 7 days and increased the cervical range of motion. Both acupuncture and manipulation reduced dizziness/vertigo on the VAS scale and had positive effects on active head repositioning. Ketoprofen percutan application and acupuncture both alleviated pain. The results of this study would suggest that spinal manipulation may impact most efficiently on the complex process of proprioception and dizziness of cervical origin.
                Copyright 2000 Harcourt Publishers Ltd. To evaluate the long-term effectiveness of a single cervical epidural steroid injection (CESI) performed with or without morphine, 24 patients, without need of surgery, but suffering for more than 12 months from cervical radicular pain, were included in a prospective and randomised study. The cervical epidural space was injected (C7-D1; 18-ga needle) with an increasing volume (10 ml maximum) of isotonic saline solution to exacerbate the patient's radicular pain. The patients were then randomly allocated to 2 groups: the steroid group (group S, n = 14) received an equivalent volume of 0.5% lidocaine plus triamcinolone acetonide (10 mg/ml) and the steroid plus morphine group (group S + M, n = 10) received the same combination plus 2.5 mg of morphine sulphate. Pain relief was assessed as the percentage of pain decrease on a visual analogue scale on day 1 and at months 1, 3, 6, 8 and 12 after CESI, up to 48 months. Anthropometric data between the 2 groups were similar. The mean volume injected in the epidural space was: 6.6 +/- 2.1 and 6.3 +/- 1.9 ml in groups S and S + M, respectively, and this volume exacerbated pain in 21 of 24 patients. Despite observing a better transient improvement the day after CESI in the S + M group, long-term results did not differ. The success rate was 78.5% in group S and 80% in group S + M providing pain relief of 86.8 +/- 14.7% and 86.9 +/- 17.9%, respectively. Pain relief remained stable with time (mean follow-up: 43 +/- 18.1 months).(ABSTRACT TRUNCATED AT 250 WORDS) To investigate the effectiveness of ultrasound treatment and trigger point injections in combination with neck-stretching exercises on myofascial trigger points of the upper trapezius muscle.
                Depression and anxiety associated with chronic pain were assessed using the Beck Depression Inventory (BDI) and the Taylor Manifest Anxiety Scale (TMAS). The study population comprised 102 patients who had myofascial trigger points in one side of the upper trapezius. The patients were randomly assigned to one of three groups: group 1 received ultrasound therapy to trigger points in conjunction with neck-stretching exercises; group 2 received trigger point injections and performed neck-stretching exercises; and group 3, the control group, performed neck-stretching exercises only. Treatment effectiveness was assessed using subjective pain intensity (PI) with a visual analog scale, pressure pain threshold (PT) with algometry, and range of motion (with a goniometer) of the upper trapezius muscle.
                Compared with the control group, patients in groups 1 and 2 had a statistically significant reduction in PI, an increase in PT, and an increase in range of motion. There were no statistically significant differences between treatment groups 1 and 2. Although not statistically significant, patients in the control group had better results at the 3-mo follow-up. The BDI scores indicated depression in 22.9% of the patient, with 4.8% of the patients having severe depression. High anxiety scores on the TMAS were present in 89.3% of the patients. When BDI and TMAS scores were compared with PI or PT levels, no significant correlations were found, but when compared with pain duration before treatment, correlations were significant.
                Patients with myofascial pain syndrome had higher scores for anxiety than for depression. When combined with neck stretching exercises, ultrasound treatment and trigger point injections were found to be equally effective. In the diagnosis of cervicogenic headache, greater occipital nerve (GON), cervical nerve, minor occipital nerve, and cervical facet joint blocks are used. In our study we compared the GON and C2/C3 nerve blocks in the diagnosis and treatment of cervicogenic headache. In both cases, repeated blocks proved to have a long-lasting effect in the treatment of this disorder, with both GON and C2/C3 blocks being found to be equally effective. Forty-four patients with chronic cervical osteoarthritis took part in this study. Patients were treated with acupuncture, sham-acupuncture, diazepam or placebo-diazepam in randomized order. Pain was rated on visual analogue scales before, during, and after treatment. Two scales were separately used to rate the intensity (sensory component) and the unpleasantness (affective component) of pain. The results analyzed from these trials show that diazepam, placebo-diazepam, acupuncture and sham-acupuncture have a more pronounced effect on the affective than on the sensory component of pain. Acupuncture was significantly more effective than placebo-diazepam (p less than 0.05), but not significantly more effective than diazepam or sham-acupuncture. nan 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.
                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.
                The results of several studies have suggested that botulinum toxin type A may reduce pain associated with myofascial pain syndromes.
                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.
                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.
                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. Aim of this investigation was the examination of the therapeutic effect of cervical nerve infiltration with mepivacaine in comparison to local applications of isotonic sodium chlorid solution in a prospective randomised double blind study.
                57 patients with cervicocephalgia or cervicobrachialgia were injected daily with mepivacaine ( n=28) or physiological sodium chlorid solution ( n=29). The success was judged through the blinded patients and blinded therapists first after three days of treatment. If no improvement occurred a single injection of mepivacaine and triamcinolonacetonid was given. This injection could be repeated if required. At the end of the inpatient treatment, after a mean of 14 days, the patients assessed the treatment according to a scale of 1-4 (painfree - no improvement).
                The average therapeutic effect, in the subjective appraisal of 1-4 by the patients, was 2.15 in the mepivacaine-group and 2.54 in the sodium chlorid - group. In the mepivacaine-group no pain (note 1) was achieved two times and 21 times a clear improvement (note 2), while in the sodium chlorid - group 18 times a clear improvement was achieved and never freedom of pain ( p<0,038). In the mepivacaine-group twice a steroidinjection was required, while in the sodium chlorid - group this was necessary in 16 cases ( p<0,01).
                Cervical injections with mepivacaine improve the subjective pain perception in cervicocephalgia and cervicobrachialgia significantly better than isotonic sodium chlorid - solution in short term results and can therefore be prefered. After an inpatient treatment good and excellent subjective results could be achieved in a high percentage. This study was designed to investigate the effects of injection with a local anesthetic agent or dry needling into a myofascial trigger point (TrP) of the upper trapezius muscle in 58 patients. Trigger point injections with 0.5% lidocaine were given to 26 patients (Group I), and dry needling was performed on TrPs in 15 patients (Group II). Local twitch responses (LTRs) were elicited during multiple needle insertions in both Groups I and II. In another 17 patients, no LTR was elicited during TrP injection with lidocaine (9 patients, group Ia) or dry needling (8 patients, group IIa). Improvement was assessed by measuring the subjective pain intensity, the pain threshold of the TrP and the range of motion of the cervical spine. Significant improvement occurred immediately after injection into the patients in both group I and group II. In Groups Ia and Ib, there was little change in pain, tenderness or tightness after injection. Within 2-8 h after injection or dry needling, soreness (different from patients' original myofascial pain) developed in 42% of the patients in group I and in 100% of the patients in group II. Patients treated with dry needling had postinjection soreness of significantly greater intensity and longer duration than those treated with lidocaine injection. The author concludes that it is essential to elicit LTRs during injection to obtain an immediately desirable effect. TrP injection with 0.5% lidocaine is recommended, because it reduces the intensity and duration of postinjection soreness compared with that produced by dry needling. Chronic pain in the cervical zygapophyseal joints is a common problem after a whiplash injury. Treatment with intraarticular injections of corticosteroid preparations has been advocated, but the value of this approach has not been established. We compared the efficacy of a depot injection of a corticosteroid preparation with the efficacy of an injection of a local anesthetic agent in patients with painful cervical zygapophyseal joints.
                Sixteen men and 25 women with pain in one or more cervical zygapophyseal joints after automobile accidents (mean age, 43 years; median duration of pain, 39 months) were randomly assigned to receive an intraarticular injection of either bupivacaine (0.5 percent) or betamethasone (5.7 mg) under double-blind conditions. The patients were followed by means of regular telephone contact and clinic visits until they reported a return to a level of pain equivalent to 50 percent of the preinjection level. The time from treatment to a 50 percent return of pain was compared in the two groups with the use of a survival analysis.
                Less than half the patients reported relief of pain for more than one week, and less than one in five patients reported relief for more than one month, irrespective of the treatment received. The median time to a return of 50 percent of the preinjection level of pain was 3 days in the 21 patients in the corticosteroid group and 3.5 days in the 20 patients in the local-anesthetic group (P = 0.42).
                Intraarticular injection of betamethasone is not effective therapy for pain in the cervical zygapophyseal joints after a whiplash injury. This study examined the effectiveness of sphenopalatine ganglion block (SPGB) for myofascial pain syndrome of the head, neck, and shoulders using a double-blind, placebo-controlled, crossover study design with comparison to an internal standard consisting of trigger point injections (TPI).
                Patients (n = 23) were randomly assigned to receive either: (1) SPGB with 4% lidocaine, then TPI with 1% lidocaine, and finally SPGB with saline placebo or (2) SPGB with saline placebo, then TPI with 1% lidocaine, and finally SPGB with 4% lidocaine. Each respective treatment within each protocol was given sequentially at 1-week intervals for both groups. Prior to the first treatment, all patients assessed their average intensity of pain and pain at that particular moment using a visual analog pain scale. Pain intensity and pain relief were reassessed 30 minutes after each treatment and at 6 hours, 24 hours and 1 week using visual analog pain and pain relief scales. Pain intensity and pain relief data were transformed into natural logarithm units, and the statistical significance of SPGB with 4% lidocaine versus SPGB with placebo, SPGB with 4% lidocaine versus TPI, and TPI versus SPGB with placebo were tested by mixed-model analysis of variance. The magnitude of the differences in pain intensity and pain relief ratings were also compared via computation of 95% confidence intervals.
                The analgesic effect of SPGB with 4% lidocaine was no better than placebo. Mixed-model analysis of variance revealed improved analgesia with administration of TPIs as compared to SPGB with 4% lidocaine and placebo over the entire week of observations (pain relief scores).
                This study suggests that SPGB with 4% lidocaine is no more efficacious than placebo and less efficacious than administration of standard trigger point injections in the treatment of myofascial pain of the head, neck, and shoulders. nan Up to 87% of patients with whiplash associated disorder (WAD) have some degree of muscle spasm that is contributory to both pain and dysfunction. Botulinum toxin A (BTX-A) produces prolonged muscle relaxation that is dose-dependent and can be easily targeted to affected muscles. BTX-A therapy may be an effective form of therapy offering an alternative or adjunct to conventional modalities. We investigated BTX-A as therapy in patients with WAD.
                This randomized, double blind, placebo controlled study compares outcome measures in 26 patients with chronic neck pain (WAD-II chronic) subsequent to a motor vehicle accident. One-half of the patients received 100 units BTX-A, diluted in 1 ml saline, while the other half received just saline (1 ml). Five trigger points received 0.2 ml each of injectant via a 30 gauge needle. Outcome measures included total subjective neck, shoulder, and head pain based on visual analog scales; objective total range of neck motion (ROM), and the Vernon-Mior subjective function index. Followup assessments were carried out at 2 and 4 weeks post-treatment.
                Fourteen subjects receiving BTX-A and 12 receiving saline completed the study. The treatment group showed a trend toward improvement in ROM and reduction in pain at 2 weeks post-injection. At 4 weeks post-injection the treatment group was significantly improved from preinjection levels (p < 0.01). The placebo group showed no statistically significant changes at any post-treatment time. The Vernon-Mior scale revealed a trend to improvement for both groups.
                BTX-A treatment of subjects with chronic WAD II neck pain resulted in a significant (p < 0.01) improvement in ROM and subjective pain compared to a placebo group, but only a trend to improvement in subjective functioning. Traditional strategies for myofascial pain relief provide transient, incomplete, variable, or unpredictable outcomes. Botulinum toxin is itself an analgesic but can also cause sustained muscular relaxation, thereby possibly affording even greater relief than traditional therapies.
                The study goal was to determine whether direct injection of botulinum toxin type A (BoNT-A) into trigger points was efficacious for cervicothoracic myofascial pain, and if so, to determine the presence or absence of a dose-response relation. One hundred thirty-two patients with cervical or shoulder myofascial pain or both and active trigger points were enrolled in a 12-week, randomized, double-blind, placebo-controlled trial. After a 2-week washout period for all medications, patients were injected with either saline or 10, 25, or 50 U BoNT-A into up to five active trigger points. The maximum doses in each experimental group were 0, 50, 125, and 250 U per patient, respectively. Patients subsequently received myofascial release physical therapy and amitriptyline, ibuprofen, and propoxyphene-acetaminophen napsylate. Follow-up visits occurred at 1, 2, 4, 6, 8, and 12 weeks. Outcome measures included visual analog pain scores, pain threshold as measured by pressure algometry, and rescue dose use of propoxyphene-acetaminophen napsylate.
                No significant differences occurred between placebo and BoNT-A groups with respect to visual analog pain scores, pressure algometry, and rescue medication.
                Injection of BoNT-A directly into trigger points did not improve cervicothoracic myofascial pain. The role of direct injection of trigger points with BoNT-A is discussed in comparison to other injection methodologies in the potential genesis of pain relief. Fifty patients with chronic resistant cervicobrachialgia were randomly divided into two groups. Twenty-five patients (group A) were treated with cervical epidural steroid/lidocaine injections and 17 patients (group B) were treated with steroid/lidocaine injections into the posterior neck muscles. Another eight patients from group B were excluded from the study because they had started the process of litigation of insurance claims and their subjective analysis of pain relief might therefore not be trustworthy. One to three injections were administered at 2-week intervals according to the clinical response. All patients continued their various pre-study treatments: non-steroidal anti-inflammatory drugs, non-opioid analgesics and physiotherapy. Pain relief was evaluated by the visual analogue scale 1 week after the last injection and then 1 year later. One week after the last injection we rated pain relief as very good and good in 76% of the patients in group A, as compared to 35.5% of the patients in group B. One year after the treatment 68% of the group A patients still had very good and good pain relief, whereas only 11.8% of group B patients reported this degree of pain relief. These differences were statistically significant. We failed to achieve significant improvement of tendon reflexes or of sensory loss in both groups, but the increase in the range of motion, the fraction of patients who were able to decrease their daily dose of analgesics, and recovery of the capacity for work were significantly better in group A. We encountered no complications in either group of patients.(ABSTRACT TRUNCATED AT 250 WORDS) To compare needle acupuncture, medication (tenoxicam with ranitidine), and spinal manipulation for managing chronic (>13 weeks duration) spinal pain syndromes.
                Prospective, randomized, independently assessed preintervention and postintervention clinical pilot trial.
                Specialized spinal pain syndrome out-patient unit at Townsville General Hospital, Queensland, Australia.
                Seventy-seven patients (without contraindication to manipulation or medication) were recruited.
                One of three separate, clearly defined intervention protocols: needle acupuncture, nonsteroidal anti-inflammatory medication, or chiropractic spinal manipulation.
                Main outcome measures were changes (4 weeks vs. initial visit) in the scores of the (1) Oswestry Back Pain Disability Index, (2) Neck Disability Index, and (3) three visual analogue scales of local pain intensity.
                Randomization was successful. After a median intervention period of 30 days, spinal manipulation was the only intervention that achieved statistically significant improvements (all expressed as percentages of the original scores) with (1) a reduction of 30.7% on the Oswestry scale, (2) an improvement of 25% on the neck disability index, and (3) reductions on the visual analogue scale of 50% for low back pain, 46% for upper back pain, and 33% for neck pain (all P<.001). Neither of the other interventions showed any significant improvement on any of the outcome measures.
                The consistency of the results provides, in spite of several discussed shortcomings of this pilot study, evidence that in patients with chronic spinal pain syndromes spinal manipulation, if not contraindicated, results in greater improvement than acupuncture and medicine. A prospective, randomized, double-blind study comparing high-dose methylprednisolone with placebo.
                To evaluate the efficacy of high-dose methylprednisolone when administered within 8 hours after whiplash injury.
                Whiplash injury often results in chronic symptoms. The management of whiplash injuries is controversial, and pharmacologic therapy has received little evaluation. In recent reports, dysfunction of the central nervous system has been indicated in several cases. Methylprednisolone administered within 8 hours after the injury to patients with acute spinal cord injury has been demonstrated to improve the outcome. This procedure was also adopted in a randomized study of cases of whiplash injury in car accidents.
                Forty patients, 22 men and 18 women with a mean age of 35 years (range, 19-65), were included in the study, 20 in each of two groups. They were treated for whiplash injury, which they had sustained in car accidents. The patients were enrolled if their diagnoses were complete and treatment had begun within 8 hours after injury. Disabling symptoms severe enough to prevent the patient from returning to work, number of sick days before and after injury, and sick-leave profile after injury were used as parameters for the evaluation of the effects of the treatment. Baseline demographic data were controlled for when statistical analysis had been performed.
                At the follow-up examination 6 months after initial treatment, there was a significant difference in disabling symptoms between the actively treated patients and the placebo group (P = 0.047), total number of sick days (P = 0.01), and sick-leave profile (P = 0.003).
                The results of this study indicate that acute treatment with high-dose methylprednisolone may be beneficial in preventing extensive sick leave after whiplash injury. However, the number of patients studied was small, and therefore further prospective, controlled studies are needed. A clinical study tested the therapeutic efficacy of Botulinum toxin A (BTXA) when injected into symptomatic neck muscles after one injection session. Patients with chronic neck pain were randomly assigned to receive either a high dose of an active treatment or an injection of the same volume of normal saline. Patients were compared for 4 months using a comprehensive set of outcome measures that included the Neck Pain and Disability Scale (Spine 24 (1999) 1290) and pressure algometry (Arch Phys Med Rehabil 67 (1986) 406; Pain 30 (1987) 115; Clin J Pain 2 (1987) 207). Analyses were consistent in showing significant benefits from the injection session; however, the effects were not specific to the group treated with BTXA. Both treatment and control groups showed a significant decline in pain and disability across time and an increased ability to withstand pressure on trigger points. The heavy incidence of adverse events in the treatment group may partly explain the absence of a treatment effect specific to BTXA. The results show that a single dose treatment without physical therapy is not effective for chronic neck pain. The study revealed that cervicobrachialgias (cervical syndrome) can be effectively treated with high-dosed neurotropic vitamins. This refers in particular to pain caused by pressure on the cervical plexus and paravertebral pain on pressur, Regarding paravertebral pain on pressure, it was possible to prove a significant superiority of the therapy with Neurotrat forte. The duration of therapy in both groups was, however, too short in order to prove a significant improvement regarding the lateral listing of the cervical spine. Both forms of treatment produced similar results in view of an improvement of impaired sensibility, paresthesia and alleviation of pain. In both groups side effects were only occasionally observed. Myofascial pain syndrome (MPS) is one of the most common causes of chronic musculoskeletal pain. Several methods have been recommended for the inactivation of trigger points (TrP).
                This prospective, single-blind study was proposed to compare TrP injection with botulinum toxin type A (BTX-A) to dry needling and lidocaine injection in MPS.
                Eighty-seven trigger points (cervical and/or periscapular regions) in 23 female and six male patients with MPS were treated and randomly assigned to three groups: lidocaine injection (n=10, 32 TrP), dry needling (n=10, 33 TrP), and BTX-A injection (n=9, 22 TrP).
                Clinical assessment including cervical range of motion, TrP pain pressure threshold (PPT), pain scores (PS), and visual analog scales for pain, fatigue, and work disability were evaluated at entry and the end of the 4th week. Additionally, depression and anxiety were evaluated with the Hamilton depression and anxiety rating scales, and quality of life was assessed using the Nottingham health profile (NHP). The subjects were also asked to describe side effects. INJECTION PROCEDURE: One milliliter of 0.5% lidocaine was administered to each TrP in the lidocaine injection group, 10-20 IU of BTX-A to each TrP in the BTX-A group, and dry needling to each TrP in the last group, followed by stretching of the muscle groups involved. The patients were instructed to continue their home exercise programs.
                Pain pressure thresholds and PS significantly improved in all three groups. In the lidocaine group, PPT values were significantly higher than in the dry needle group, and PS were significantly lower than in both the BTX-A and dry needle groups. In all, visual analog scores significantly decreased in the lidocaine injection and BTX-A groups and did not significantly change in the dry needle group. Disturbance during the injection procedure was lowest in the lidocaine injection group. Quality of life scores assessed by NHP significantly improved in the lidocaine and BTX-A groups but not in the dry needle group. Depression and anxiety scores significantly improved only in the BTX-A-injected group.
                Injection is more practical and rapid, since it causes less disturbance than dry needling and is more cost effective than BTX-A injection, and seems the treatment of choice in MPS. On the other hand, BTX-A could be selectively used in MPS patients resistant to conventional treatments. To evaluate the analgesic effectiveness of subcutaneous carbon-dioxide insufflations in addition to standard physical treatment in patients with non-specific neck or low back pain.
                A pragmatic, randomized controlled trial. Setting: Rehabilitation hospital inpatients.
                Patients received either subcutaneous carbon-dioxide insufflations (10 treatments) and standard physical treatment or standard physical treatment only. Outcome measures: Affective pain perception (42-point scale), sensory pain perception (30-point scale), pain intensity (100 mm visual analogue scale).
                Between-groups differences were -2.2 [95% CI -5.2; +0.9] (affective pain perception), -1.2 [-3, 0; + 0.7] (sensory pain perception), and -6.5 [-14; +1.0] (pain intensity) respectively in favour of subcutaneous carbon-dioxide insufflations.
                Subcutaneous carbon-dioxide insufflations do not seem to be a worthwhile adjunct in the given setting of inpatient rehabilitation. Trials in a monotherapeutic setting, which aim more at the efficacy of subcutaneous carbon-dioxide insufflations, might help to solve this issue. This double-blind study of the effects of diazepam on painful cervical muscle spasms compared with those of phenobarbital and an inert placebo employed clinical, electrogoniometric and electromyographic recording methods for evaluation and computer analysis. The clinical results were equivocal but the technological recordings revealed a statistically significant greater desirable effect of diazepam compared to the other 2 treatments which would be expected to have only minor nonspecific effects. Ketorolac tromethamine injected intramuscularly (IM) has been shown to be an effective analgesic in treating patients with acute musculoskeletal pain in the emergency department (ED). The authors compare the efficacy of a single dose of IM ketorolac to osteopathic manipulative treatment (OMT) as delivered in the ED for the management of acute neck pain. A randomized clinical trial was conducted in three EDs. A convenience sample of 58 patients with acute neck pain of less than three weeks' duration were enrolled. Subjective measures of pain intensity on an 11-point numerical rating scale were gathered from patients immediately before treatment and one hour afterward. Subjects received either OMT or 30 mg, IM ketorolac. Subjects' perceived pain relief was also recorded at one hour after treatment on a subjective 5-point pain relief scale. Twenty-nine patients received IM ketorolac, and 29 patients received OMT. Although both groups showed a significant reduction in pain intensity, 1.7+/-1.6 (P <.001 [95% CI, 1.1-2.3]) and 2.8+/-1.7 (P <.001 [95% CI, 2.1-3.4]), respectively, patients receiving OMT reported a significantly greater decrease in pain intensity (P=.02 [95% CI, 0.2-1.9]). When comparing pain relief at one hour posttreatment, there was no significant difference between the OMT and ketorolac study groups (P=.10). The authors found that, at one hour posttreatment, OMT is as efficacious as IM ketorolac in providing pain relief and significantly better in reducing pain intensity. The authors conclude that OMT is a reasonable alternative to parenteral nonsteroidal anti-inflammatory medication for patients with acute neck pain in the ED setting. Seventy-eight patients, 40 suffering from cervical arthrosis and 38 from lumbar arthrosis, received for a period of two weeks paracetamol or a new preparation of glaphenine, in a double blind study. The two drugs were found to have the same efficiency on the subjective parameters but high bioavailability glaphenine seems to have an effectiveness in the range of articulatory movements, which is not found with paracetamol. The side effects were quite equivalent.
The major limitations are the lack of replication of the findings and sufficiently large trials. There is moderate evidence for the benefit of intravenous methylprednisolone given within eight hours of acute whiplash, from a single trial. Lidocaine injection into myofascial trigger points appears effective in two trials. There is moderate evidence that Botulinum toxin A is not superior to saline injection for chronic MND. Muscle relaxants, analgesics and NSAIDs had limited evidence and unclear benefits.