Intractable neck pain

Chronic Pain Following Motor Vehicle Collision: A Systematic Review of Outcomes Associated With Seeking or Receiving Compensation

OBJECTIVE

Motor vehicle collisions (MVC) are a major cause of injury, which frequently lead to chronic pain and prolonged disability. Several studies have found that seeking or receiving financial compensation following MVC leads to poorer recovery and worse pain. We evaluated the evidence for the relationship between compensation and chronic pain following MVC within a biopsychosocial framework.

METHOD

A comprehensive search of 5 computerized databases was conducted. Methodological quality was evaluated independently by 2 researchers according to formal criteria, and discrepancies were resolved with a third reviewer.

RESULTS

We identified 5619 studies, from which 230 full-text articles were retrieved and 27 studies were retained for appraisal. A third of studies (37%) were of low quality, and 44% did not measure or control for factors such as injury severity or preinjury pain and disability. Most studies (70%) reported adverse outcomes, including all of the highest quality studies. Engagement with compensation systems was related to more prevalent self-reported chronic pain, mental health disorders, and reduced return to work. Recovery was poorer when fault was attributed to another, or when a lawyer was involved. Five studies compared Tort "common law" and No-Fault schemes directly and concluded that Tort claimants had poorer recovery.

CONCLUSIONS

Although causal relationships cannot be assumed, the findings imply that aspects of loss, injustice, and secondary mental health outcomes lead to chronic pain following MVC. Further robust prospective research is required to understand the complex relationship between compensation systems and pain following road trauma, particularly the role of secondary mental health outcomes.

The differential diagnosis of toothache from other orofacial pains in clinical practice

BACKGROUND

Teeth are a common and obvious source of orofacial pain. There is a risk that endodontic treatment may be initiated in patients that do not have pulp or periapical pathosis.

METHODS

A retrospective survey of a sample of patients referred for endodontic treatment was analysed to determine the accuracy of the diagnosis and to identify non-dental cases. A separate prospective study of complex non-dental orofacial pain cases was performed to determine which cases had previously received dental treatment.

RESULTS

Seventy-seven (88 per cent) of 88 patients referred for endodontic treatment had been correctly diagnosed with solely endodontic problems. Eight (9 per cent) had endodontic plus other orofacial pain problems and three (3 per cent) had no endodontic problems but other orofacial pain problems. Forty-four (44 per cent) of 100 non-dental orofacial pain patients had previously received either extractions or endodontics.

CONCLUSION

Dentists need to carefully evaluate all toothache patients to ensure that the diagnosis is correct prior to the initiation of irreversible treatment.

The outcome of control groups in clinical trials of conservative treatments for chronic mechanical neck pain: a systematic review

Background

Chronic neck pain is highly prevalent in Western societies, with about 15% of females and 10% of males suffering with it at any time. The course of untreated chronic neck pain patients in clinical trials has not been well-defined and the placebo effect has not been clarified.

Methods

A systematic review of RCT's of conservative treatments for chronic mechanical neck pain was conducted. Studies were excluded if they did not include a control group, if they involved subjects with whiplash injuries, a predominance of headache or arm pain associated with chronic neck pain and if only one treatment was reported. Only studies scoring 3–5 out of 5 on the Jadad Scale for quality were included in the final analysis. Data on change in pain scores of subjects in both placebo (PL) as well as no-treatment (NT) control groups were analyzed. Mean changes in pain scores as well as effect sizes were calculated, summarized and compared between these groups.

Results

Twenty (20) studies, 5 in the NT group and 15 in the PL group, with outcome intervals ranging from 1–52 weeks were included in the final analysis. The mean [95% CI] effect size of change in pain ratings in the no-treatment control studies at outcome points up to 10 weeks was 0.18 [-0.05, 0.41] and for outcomes from 12–52 weeks it was 0.4 [0.12, 0.68]. In the placebo control groups it was 0.50 [0.10, 0.90] at up to 10 weeks and 0.33. [-1.97, 2.66] at 12–24 weeks. None of the comparisons between the no-treatment and placebo groups were statistically significant.

Conclusion

It appears that the changes in pain scores in subjects with chronic neck pain not due to whiplash who are enrolled in no-treatment and placebo control groups were similarly small and not significantly different. As well, they do not appear to increase over longer-term follow-up.

Elevated detection thresholds for mechanical stimuli in chronic pain patients: support for a central mechanism

OBJECTIVE

To investigate the relation between pain provoking cervical segments identified by diagnostic dorsal root blockades and elevation of detection thresholds in patients suffering from chronic cervicobrachialgia (CCB).

DESIGN

Quantitative sensory testing (light touch) of the cervical dermatomes using Semmes-Weinstein monofilaments.

SETTING

A university pain clinic.

SUBJECTS

Thirty-nine patients with CCB, with no clinical or diagnostic evidence of radiculopathy or surgically treatable bony lesion and with one main pain-provoking cervical segment identified by diagnostic dorsal root blockades.

OUTCOME MEASURES

Detection thresholds with 95% confidence intervals (95% CI) of pain-provoking segments, compared with surrounding and contralateral segments and with normal values for cervical dermatomes.

RESULTS

Patients' detection thresholds were significantly (p < .001) higher than those for normal subjects: 3.51 (95% CI, 2.71-4.31) and 3.10 (95% CI, 2.34-3.86), respectively. No significant differences existed between the segments. The elevations were systematic. However, thresholds on the painful side were consistently, slightly higher than those on the contralateral side.

CONCLUSION

Supporting earlier studies, results from CCB patients in the present study showed systematic elevation of detection thresholds (low threshold mechanoreceptors), an adaptation in contrast with, but not contradictory to, central sensitization of high threshold neurons in chronic pain.