Fibromyalgic syndrome and orofacial neuropathic pain are major public health concerns affecting up to 5% and 10%, respectively, of the general population. They generally require medications such as antidepressants and anticonvulsants, which may additionally impact the quality of life with their side effects. Modern technologies and related applications have changed several fields of human life, even in medicine. In the current study, the local administration of electromagnetic fields as add-on therapy for the treatment of cervical and facial pain in patients with fibromyalgia or neuropathic pain has been evaluated. A total of 15 patients were recruited, and an electromagnetic field was delivered through a small patch applied between C3 and C4. Patients were followed for 12 months, and pain levels were rated via the VAS scale; ∆% was calculated through the analysis of median VAS scale values at each time point. Mild-to-moderate improvements were found, especially after six months. Patients with fibromyalgic syndrome showed better response rates than those with orofacial neuropathic pain. Joint stiffness, masticatory fatigue, and sleep disturbances were also reduced. In conclusion, the local application of electromagnetic field appeared effective in treating fibromyalgic and neuropathic pain in the head and neck district, with broader improvements and no side effects. In the broad range of chronic pain disorders, neuropathic pain and fibromialgic syndrome (FS) represent common burdens affecting the worldwide population. Neuropathic pain, basically, describes a group of conditions with a wide range of causes and different pain distributions characterized by a lesion or disease affecting the somatosensory nervous system, both peripherally and centrally ,2. It afSimilarly, FS represents an idiopathic and complex chronic syndrome, defined as long-lasting, widespread, and symmetric non-articular musculoskeletal pain with generalized tender points at specific anatomical sites ,9. FS isTherapeutic approaches should be directed toward an integrated treatment plan based on medications, patient education, physical activity, and cognitive-behavioral therapy ,17,18. AIn the present scenario, the authors of the present study hypothesized the applicability of an emerging therapeutic protocol based on EMF therapy. A pilot study was designed in order to establish the background for subsequent more structured studies. A new medical device called Hologies-Orofacial Neuropathic Pain (HO-ONP)  was used as adjuvant therapy to properly prescribed drugs in the treatment of pain in patients affected by FS or ONP.The present study is an observational pilot study. The STROBE checklist guidelines have been followed. The initial sample was made by 28 individuals, sent to us by the Pain Center of the University of Cagliari. All the patients were diagnosed with FS or ONP. A total of 13 individuals were excluded after the application of inclusion and exclusion criteria. Inclusion and exclusion criteria are reported in In the final sample, a total of 15 individuals were included, 10 with FS and 5 with ONP, all females, ranging from 28 years old up to 65. Two authors (MS and ES) examined and followed patients for the whole observational period, that was 12 months, at the Orofacial Pain Center of the University of Cagliari under the supervision of one independent coordinator (NZ). The kappa test was run to evaluate the level of agreement between these experts, and it was found to be 0.58, thus “moderate” . Any disThe aim of the study was to evaluate the effectiveness of HO-ONP in pain management in patients with ONP and FS as an adjunct therapy to prescribed drugs (see below). Additionally, the possible presence of any differences in the responsive rate between patients suffering from FS and those suffering from ONP were investigated.The current study has been developed in agreement with the good clinical practice guidelines provided by the Declaration of Helsinki  and has The present pilot study has been developed according to the following 7 steps: (1) Medical examination: sites and origins of pain were evaluated; hyperalgesia and allodynia were searched by wiping a cotton roller and a pointed probe on the skin of both sides of the face and neck. The average level of pain felt was reported on the VAS scale. VAS scale is a 100 mm line anchored to a verbal description of pain from “no pain” to “the worst ever pain”. Patients are asked to mark that line approximately to indicate the level of pain ; patient3 (after 1 h), t4 (after 6 h), and t5 (before sleeping) for the first day only. Then, from the next day and for the entire duration of the follow-up, patients must have taken note at t6 (after awakening), at t7 (during the afternoon), and at t5 for each following day. (4) First check: the next week (T1), patients were recalled to the department to analyze potential rapid improvements in symptomatology and eventual unprogrammed side effects and to see if patients understood how to sign the VAS scale. (5) Second check: one month later (T2) to evaluate further improvements and eventual side effects. Then patients were recalled every month for the following year. (6) Third check: 6 months after the application (T3). (7) final check: after 12 months (T4) for the overall evaluation of the patch in the final detailed report.Patients suffering from FS continued to follow the pharmacological protocol established previously by the Pain Center of the Hospital of the University of Cagliari: Duloxetine 30 mg/daily in the morning, eperisone hydrochloride 100 mg/once or twice per day, Clonazepam 5/7 drops before bedtime and magnesium 3 to 4.5 mg/kg per day. Patients with ONP continued instead to receive amitriptyline 12.5 to 25 mg/daily or pregabalin 150 to 300 mg/daily. (2) Application: the pulsed EMF was delivered through a small and flexible patch, 2 × 3 cm sized, that was comfortably wearable. The patch was applied by trained staff between C3 and C4 vertebra. Patients registered the pain level on the VAS scale at T0 (0 s). Patients were informed about the management of the patch and the need to change the position of the same sometimes to avoid the occurrence of tolerance. (3) At home, patients must have taken note of the pain level on the scale VAS at tData were entered into a spreadsheet (MS Excel Office 365 MSO), and Gretl  was the software used to perform the statistical analysis. ∆% was calculated through the analysis of median VAS scale values at each time point. The choice to carry out this type of test was taken by virtue of the low sample numerosity. The test does not require making assumptions about the distribution of the population.p < 0.05, and analyses were performed using the statistical software Stata .The significance of changes in VAS score was evaluated by Friedman’s nonparametric two-way analysis of variance. Post-hoc analysis was performed by Wilcoxon signed-rank test with Bonferroni test. Statistical significance was set at The current study analyzed the responsiveness of a total of 15 patients affected by FS or ONP to low-frequency EMF-based therapy. Median VAS scale values were registered at each check. Data were entered into a spreadsheet (MS Excel Office 365 MSO). The median values of the daily VAS scale were first calculated for each patient and then at T0, T1, T2, T3, and T4. Subsequently, a comparison was made, and the ∆% was calculated for each patient. ∆% resulted through the analysis and the comparison of each signed VAS scale of each patient, and it was calculated in order to verify whether the investigated treatment was effective. A global analysis was firstly performed, then patients were divided into two groups according to the disease they suffered from, namely FS or ONP, and ∆% was calculated for each group.A decrease in pain levels in the overall sample was detected during the observational period between the initial stage and the following checks . Median p < 0.001). Moreover, VAS score assessed at each time point significantly differ from VAS score measured at baseline   .Similar results appeared if considered separately the 10 patients affected by FS  to thosePatients with FS asserted furthermore benefits concerning several other symptoms. Reduced morning shoulder joint stiffness, partially but not completely, and diminished headaches, in both intensity and occurrence were reported by 8 out of 10 individuals. Additionally, masticatory fatigue was solved. Due to such improvements, the same patients reported having reduced physical therapy related to the neck and shoulders. Interestingly, significant self-reported enhancements in daily mood and in sleep were described. Reduced difficulties in falling asleep and lesser habitual nocturnal awakenings were the major clinical improvements referred by seven patients with both FS and ONP. In spite of such improvements, in patients with FS, the symptomatology related to all the other body regions was still present. Lastly, all the patients did not complain about the ergonomics and comfort of the therapeutic patch, and no side effects were reported.The purpose of the authors was to evaluate the effectiveness of the local administration of low-frequency EMF as an add-on therapy for chronic pain in patients with FS and ONP.Low-frequency EMF therapy was demonstrated to be safe, noninvasive, and easy to use in the treatment of pain, with important effects in the control of different painful musculoskeletal disorders ,42,43. SFoley-Nolan et al. , in a raIn line with such evidence, we hypothesized the applicability of EMF as an adjuvant treatment in FS and ONP. In the current pilot study, the EMF is delivered through the communication among nanocrystals and semiconductors targeted with appropriate and desired signals. The specific signal is delivered through low electromagnetic frequencies and works in the oxy-hemoglobin wavelength by virtue of its ability to provide optimal noninvasive in vivo monitoring . The sigIn the current study, the analysis of the results may conclude that EMF proved effective as an add-on therapy in the treatment of both FS and ONP. Important short-term and long-term benefits were reported by the majority of patients. A significant reduction in pain intensity was evident already after the therapy was administered. After 1 week (T1), a median 2 points-level improvement was assessed on the VAS scale.p = 0.002, p = 0.004, p = 0.010, and p = 0.010 at T1, T2, T3, T4, respectively. It can be concluded that mild-to-moderate improvements were reported throughout the follow-up, with the major peak reached after six months. The progressive physical deterioration of the patch may be responsible for the improvements’ reduction at 12 months. Another hypothesis that should not be neglected is the possibility that a process of tolerance has been established. Future studies need to address this aspect.Mild further improvements were reported after one month, while a significant additional decrease was observed after 6 months. During the final check, i.e., 12 months after the application, a 2.55 points-level improvement emerged through the analysis of the VAS scale. In line with clinical evidence, statistical significance emerged at each time point, Patients with FS appeared to respond better to EMF therapy than those with ONP. Assumed the very low numerosity of the ONP sample, only one out of five patients referred significant improvements in pain. Conversely, 40% of patients with FS reported an important reduction in pain. Furthermore, most treated patients with FS reported significant benefits regarding several other symptoms we initially did not consider. Rediscovered refreshed sleep, decreased headaches in intensity and occurrence, and reduced physical stiffness and functional limitations in movements were all reported. Patients additionally improved their daily mood, suggesting the primary impact on the quality of life of FS and ONP. Such results further supported the global improvements in pain, fatigue, and quality of life found by Sutbevaz et al. when pulsed EMF was delivered to patients with FS .Additionally, a possible and direct influence of low-frequency EMF was suggested on the emotional component of pain . InteresAnother outcome worthy of mention is the absence of any side effects reported since we asked patients to inform us continuously about each possible adverse eventThe last parameter to consider regards the ergonomics of the device: all individuals undergone the study have not referred complaints about the comfort because the patch appeared to be easy to use, not awkward or bulky, and without any need for a power supply system such as other medical equipment working via electromagnetic waves.The current study has several limitations due to the sample’s characteristics. Low numerosity is a major weakness. Furthermore, the limitation of providing only a localized effect gives rise to the need for further research. Indeed, the possibility to gain a systemic covering may lead to improvements in the quality of life of such patients and may potentially reduce the assumption of medications. The inclusion of only women in the final sample was expected because of epidemiological data related to both diseases.In conclusion. albeit the low numerosity sample of our study and thus all the annexed limitations, we can support the benefits given by the local administration of low-frequency EMF in relieving head and neck pain in patients with both FS and ONP. However, patients suffering from FS appeared to better respond to the treatment. Additionally, a wider range of improvements concerning sleep, function, and mood also emerged in FS patients.


The SPA service takes referrals from general practitioners (GPs), medical professionals, the London Ambulance service, the London Police, psychology and social services, and from patients themselves and their family members or support groups. Some of these referrals require input from secondary care, but others can be solved within primary care if given specialist advice, this minimizing the time spent by patients in the healthcare system and minimizing also the NHS costs.Our aim was to evaluate the implementation of the Advice from Medics Service in a 1-year period.We examined a random sample of 200 referrals between 1st of April 2019 and 31st of March 2020 out of all referrals that were considered, after the triage, to be appropriate for an advice on treatment provided by the medics as an alternative to a clinic appointment in secondary care. We collected information from the electronic patient records regarding the dates of referrals, the senders of referrals, the type of referrals, the age and gender of patients and the reasons to be referred, and finally we analysed the outcome of the referrals and compared it with the action requested.Of the 200 referrals, 113 were for female patients and 87 for male patients. The age of patients was between 18 and 91 years old, with a median of 43 years old.The person/authority making the referral was the GP in 179 cases, and others in 21 cases.The referrers asked for review in 74 cases, urgent review in 2 cases, review and advice in 31 cases, only advice in 46 cases, and did not state the type of referral in 47 cases.The primary pathology implied was affective in most of the cases (122), followed by psychotic (31) and neurotic (22), organic (8), of personality (5), hyperkinetic disorders (5), due to substance misuse (4), of psychological development (2) and learning disability (1).The outcome of the referrals was as follows: 19 patients (9.5%) were seen by the Crisis Team, 11 (5.5%) were referred to other teams, 4 (2%) did not engage with SPA, and the rest of 166 (83%) referrals were solved with advice.The outcome was extremely favourable as the majority of referrals requested medical review but most of them (83%) were solved with specialist advice to GPs or other professionals, highlighting that the implementation of the Advice from Medics Service has been an improvement to the SPA.


BackgroundOsteoarthritis (OA) is a degenerative disease commonly affecting the knee joints. It affects patients socially, psychologically and economically and rates of the disease have been increasing due to obesity and old age. Regardless of choosing a medically conservative approach, it is a challenge in the long term to provide OA patients efficient treatment with minimal side effects and long-term efficiency. Platelet-rich plasma (PRP) is a convenient, low-cost and affordable treatment technique used in treating knee OA with encouraging efficient and safe outcomes. In this study we will investigate the effect of PRP on knee OA.MethodsThis is a prospective cohort study involving 252 patients with different OA grades. The Kellgren and Lawrence (K&L) system was used in classifying the affected knee by degenerative cartilage lesions as well as early and severe OA. All patients with a diagnosis of knee OA were screened in every visit before the injection, the pain was assessed by the 0-10 Numeric Rating Scale (NRS), and knee range of motion including flexion and extension was assessed by goniometer. Follow-up appointments were done on three-month intervals for a total of three visits for evaluation. Injection of PRP was given to all the patients with a maximum of four injections. The results were evaluated statistically according to the total number of follow-up visits.ResultsIn grade II patients, the pain improved with the visits and the maximum improvement in flexion degree was noticed in patients who came for a total of three follow-up visits. In grade III patients, the most improvement in pain was in patients who came for three follow-up visits, while the most improvement in flexion degree was in patients who came for a total of two follow-up visits. Patients with grade IV who came for three follow-up visits showed the most improvement in pain and degree of flexion.ConclusionsIntra-articular injections gave significant pain and flexion improvement in grades II, III and IV in OA patients, especially with multiple injection in the short-term follow-up. As a result, recommendation of repeated multiple injections up to four times is efficient in providing long time relief in knee OA. Osteoarthritis (OA) is the most common type of arthritis and degenerative disease affecting around 250 million globally . It affeThe articular cartilage is composed of hyaline cartilage, which protects the subchondral bone, redistributes the applied loads, acts as a shock absorber and with the presence of synovial fluid reduces the friction inside the joints. Moreover, growth factors and cytokines including insulin-like growth factor 1 (IGF1), fibroblast growth factor (FGF) and transforming growth factor-beta (TGF-ϐ) play a critical role in the control of chondrogenesis, directing the differentiation of mesenchymal stem cells into mature chondrocytes . Under nPlatelet-rich plasma (PRP) is a convenient, affordable treatment technique used in treating knee OA with encouraging efficient and safe outcomes. Furthermore, it is capable of producing a biological process that gives ambitious results in treating patients with OA . The autThis is a prospective cohort study that was done by the orthopedic outpatient clinic at King Abdulaziz University in Jeddah, Saudi Arabia between June 2018 to June 2019 and was approved by the Institutional Review Board (IRB) of King Abdulaziz University. We included patients who had a confirmed diagnosis of OA with presence of osteoarthritic changes in their radiographic imaging. Meanwhile, we excluded all the patients who had grade I OA, a single PRP injection only, previous intraarticular fracture, previous septic arthritis, previous intra-articular injection of corticosteroids, known cases of rheumatoid arthritis and known cases of anemias. A total of 252 patients with either unilateral or bilateral knee OA with a total of 260 knees were included in the study. All patients had complete blood count (CBC) and a weight-bearing view x-ray done. The grade of OA was determined according to the Kellgren-Lawrence (KL) grading system . ConsentThe range of movement as flexion and extension was measured using a goniometer. A Phlebotomy technician withdrew 7ml blood from the patients for each joint using a Regen Lab SA  tube and centrifuged it at a speed of 36,000 rounds/min for six minutes. Afterward, separated plasma was obtained and injected immediately in the prepared knee under a completely aseptic environment Figure .We injected 5cc of PRP to the affected knees 1 cm lateral to the patellar tendon and 1 cm below the joint line Figure . FinallyIn our study, a total of 260 knees with osteoarthritis ranging between grades 2 to 4 were treated with PRP injections. The average age of participants was 61.46 ± 8.94 and most of them were females (76.9%). Furthermore, both knee sides were almost evenly distributed with the left knee  slightly more than the right knee . Regarding BMI, around one-third of the patients were overweight  and around one-third were class I obese . Out of the 260 osteoarthritic knees included, 68 (26.2%) were grade II OA, 112 (43.1%) were grade III OA and 80 (30.8%%) were grade IV OA. Moreover, a total of 124 (47.7%) knees had a total of two PRP injections, 92 (35.4%) had a total of three, and only 44 (16.9%) needed a total of four injections  with the mean average number of visits 2.69 ± 0.74.o to 121.90o . Meanwhile, in patients who received three PRP injections (n = 12 knees), the pain was reduced from an average of 6.67 in the initial visit  to 5 in the first follow-up but slightly increased to an average of 5.67 in the second follow-up and was statistically significant . Regarding the change in the degree of flexion, a small increase was noted from 122.33o in the initial visit to 123.33o in the first follow-up  and was further reduced in the second follow-up to 114o . Lastly, patients who received four PRP injections (n = 16 knees) showed no significant change in pain between the initial visit and the first follow-up, however, a change was noticed in the second follow-up as the pain decreased from an average of 6.25 in the first follow-up to a 4.75 in the second visit and substantial decrease to an average of 2.25 in the third visit. Interestingly, they were found to be statistically significant during the second and third follow-up . Similarly, for changes in the degree of flexion, there was a small increase from 120.25o in the initial visit to 123.75o in the first follow-up, reduced to 118.25o in the second follow-up, and improved to 126.50o in the third follow-up and were significant in both the second and third follow-up (Table For patients with grade II OA who received two PRP injections (n = 40 knees), there was a marked drop in pain from an average of 6 to 3.8 between the initial visit and the second follow-up and was statistically significant . However, there was no remarkable decrease in the degree of flexion as it decreased from 122.10o to 113.23o . For patients who received three PRP injections (n = 48 knees), there was a decrease in pain from 6.67 in the initial visit to 4.08 in the first follow-up , followed by a non-significant increase in the second follow-up . Regarding the change in the degree of flexion, there was a gradual increase in the degree from 114.33o in the initial visit to 115.33o in the first follow-up  and a significant increase of 121.42o in the second follow-up . Lastly, for patients who received four PRP injections (n = 12 knees), there was a significant improvement of pain throughout three follow-ups as well as in degree of flexion . The pain started at 7.67 and decreased to 6.33 in the first follow-up, decreased further to 5.33 in the second visit, and decreased substantially to an average of 3.33 in the third one. In the same context, the degree of flexion increased from 123.33o to 124o in the second follow-up, then to 127o in the third visit (Table For patients with grade III OA who received two PRP injections n = 52 knees), there was a significant reduction in pain from 7 in the initial visit to 5.85 in the follow-up , and a small increase in the degree of flexion from 110.31 knees, to in the initial appointment to 112.38o in the follow-up . For patients who received three PRP injections (n = 32 knees), the average pain score was at a plateau level of 5.8 in all visits with no significant changes. However, regarding the difference in the degree of flexion, there was no significant change between the initial visit and the first follow-up appointment but there was an increase from 105.63o in the first visit to 109o in the second visit . For patients receiving four PRP injections (n = 16 knees), there was a gradual decrease in pain score from 8.5 in the initial visit to an average of 6.5 in the first follow-up  and a further decrease of average score of 4.25 in the second follow-up , followed by a slight increase to 5.25 in the third follow-up visit . For the change in the degree of flexion, there was a significant gradual improvement from 108.75o in the initial visit to 115o in the first follow-up  but no significance was found in the second follow-up where the average flexion degree was recorded at 117.25o, then decreased to 114.25o in the third follow-up visit (Table For patients with grade IV OA who received two PRP injections n = 32 knees), there was an improvement in pain from 7.62 in the initial visit to 5.25 in the follow-up  and the degree of flexion increased from 111.632 knees, The knee joint is the most common joint affected by osteoarthritis while total knee arthroplasty (TKA) is usually indicated for late-stage cases not responding to different modalities of conservative methods and medication as a last resort. It is estimated that up to one-third of TKA patients experience chronic pain postoperatively resulting in a reported low outcome rate of 20% . HoweverPRP is an autologous or allogenic blood-derived component composed of concentrated platelet of the blood, which can activate and accelerate repair of the connective tissue. Ever since the first research about PRP, which was done by Sampson et al. , there wOther studies that were done to investigate the efficacy of a single or multiple PRP injections for knee OA showed that a single injection was as effective as multiple PRP injections in pain improvement. However, multiple injections seemed more effective in joint functionality than a single injection at a six-month interval ,22. Receo. Although, in our study, grade II OA knee flexion did not improve except in the patients who received a total of four PRP injections, the overall pain decreased in all grade II groups. This finding is directly in line with Dhillon et al.'s conclusion that PRP injections are an effective treatment for early-stage knee OA symptoms ..o. HowevDespite the positive outcomes that are reported in the literature, the diversity of the methodological studies that include preparation, administration and intervals of the injection. Furthermore, details on storage, centrifugation speed and time for plasma isolation can be variable and have an unnoticed effect on the process. Moreover, the cost of treatment was not explored in our study with having up to four injections. However, we followed the most common interval used of four weeks but a fourth injection was added to explore the effectiveness of the treatment.In this study we demonstrated that intra-articular injection of PRP in OA knee in grades II, III and IV are valuable, efficient and cost-effective. Patients observed a decrease in pain and an increase in degree of flexion. The changes were noticeable short term after three, six and nine months of follow-ups. Grade IV gave a good response to injection with improvement in pain and range of flexion, which as a result decreased the possibility of needing TKA or delayed it. Multiple injections gave better results than single injection in all grades regardless of their weight.


This study aimed to compare the effectiveness of three acupuncture methods for temporomandibular disorders- (TMDs-) related pain. p > 0.05).  Different locations of pain, according to DC/TMD clinical assessment, were considered: temporomandibular joint (TMJ), masticatory muscles, head, and neck. Sixty patients were assigned randomly to one of three treatment groups (20 patients in each): group BA received body acupuncture, group EA received electroacupuncture, and group CA received acupuncture + cupping. The groups were compared in terms of pain , pain-related disability , and impression of the treatment's effectiveness . These were recorded before sessions of acupuncture treatment (T0), after 8 sessions of acupuncture treatment (T1), and after 4 weeks of follow-up after treatment (T2). The between-group and within-group differences in the data were analyzed statistically. The baseline characteristics were similar in all groups (p < 0.05). No significant differences were noted in the improvement of TMDs-related pain according to the different acupuncture techniques . All acupuncture methods used resulted to be significantly effective in improving the pain-related interference in the patient's common activities and quality of life. EA resulted to be significantly more effective than BA and CA in improving the interference of pain with patients' mood (p=0.015) and quality of sleep (p=0.014).  Significant improvements were noted in all types of pain compared to baseline values in all groups (all  BA, EA, and CA are all effective acupuncture methods in reducing pain and pain interference with common activities and quality of life in patients affected by TMD. Temporomandibular disorders (TMDs) are considered as one of the major causes of orofacial pain . Pain reBody acupuncture is the most common type of acupuncture treatment; it involves the insertion of needles into the selected acupoints, which are manually stimulated by the operator until the achievement of the proper feel of the needling with acupuncture called “Deqi.” This method is actually the most investigated in the orofacial pain field, followed by laser acupuncture, as well as different microsystem acupuncture methods, such as ear, scalp, mouth, and fingers [Electroacupuncture is a form of acupuncture extensively studied for its analgesic effects [Cupping therapy belongs to traditional Chinese medicine (TCM), dating back at least 2,000 years. It consists in using one of several kinds of cups  placing them on the desired acupoints or sore spots on patients' skin, producing hyperemia or hemostasis, which results in a therapeutic effect [Although many of acupuncture's physiological and neurological mechanisms are still unknown, the efficacy of acupuncture for pain therapy has been well established , 10. In  fingers –20. Elec effects –23. This effects , 23. Cupc effect . This mec effect , 25. A sc effect  analyzedAlthough many studies have assessed the significant effects of different types of acupuncture treatment on TMD-related pain, the conclusions are inconsistent. In particular, due to the lack of direct comparison of different methods of treatment, it is not conducive to the choice of clinical application and the implementation of the best treatment. Therefore, the aim of this clinical study was to evaluate and compare the effectiveness of three different methods of acupuncture treatment  in alleviating pain and their interference in common activities and quality of life of patients affected by temporomandibular disorders.This clinical study was conducted at the Clinical Gnathology Unit of the Department of Oral and Maxillofacial Sciences at the “Sapienza” University of Rome. The study was approved by the Institutional Ethics Committee (N.47/19/0001155); all patients signed an informed consent document before participating in the study.During the period of February 2019–March 2021, 466 subjects under observation in our department were assessed for eligibility. All patients were screened for temporomandibular disorder (TMD) by specialists in the field and calibrated in using the DC/TMD diagnostic criteria [Since there were no data available from other clinical studies about the comparison of different acupuncture methods for the treatment of TMD-related pain, patients were recruited using convenience sampling. The patients who met the inclusion criteria were assigned randomly to three different acupuncture treatment groups. An independent investigator used a random number generator (Research Randomizer©) to allocate participants into each group by block randomisation in a 1 : 1 : 1 ratio. The results of random allocation were sealed, such that they cannot be seen from outside, stored, and managed at the Clinical Gnathology Unit. Before treatment, a random envelope was opened in front of the enrolled participant by the treatment provider. The random allocation numbers assigned to each group were recorded in an electronic chart, and no changes were allowed after allocation.Given the characteristics of the treatments, this study does not allow the participant or treatment provider to be blinded to their group; thus we used a single-blinded design, where only the assessors were blinded. Participants were assessed away from the acupuncture treatment area by investigators who did not participate in treatment procedures and were blinded to the treatment group. The statistician was not involved in randomisation and analyzed the data without having access to information about allocation.The treatment protocol was developed according to the treatment methods used in traditional Chinese medicine (TCM) , 15, witPatients assigned to the first group were treated with body acupuncture (BA). The acupuncture points used were ST6 (Jiache), ST7 (Xiaguan), GB20 (Fengchi), BL10 (Tianzhu), LI4 (Hegu), ST36 (Zusanli), SP6 (Sanyinjiao), and LR3 (Taichong). After asepsis of the skin with 70% alcohol at the needle penetration site, the needles were inserted bilaterally. The needles were disposable and sterilized, individually packed, with size of 0.25 × 25 mm . The depth of needle penetration varied considering the anatomical differences of the application sites in each patient. The needle was manipulated clockwise and counterclockwise to achieve the proper feel of needling with acupuncture called “Deqi.”Patients assigned to the second group were treated with electroacupuncture (EA). The acupuncture points used in this group were the same acupoints selected in the BA Group, as well as the needle penetration procedure and timing, and the needle's size and characteristics. In the EA group, an electrical apparatus  producing a dense-dispersed wave with a frequency of 1/100 Hz was connected to the needles with alligator clips to stimulate pairs of needles inserted at ST36-SP6 and LI4-GB20. The fixed current intensity was uniformly 0.2 mA.Patients assigned to the third group were treated with acupuncture combined with cupping therapy (CA). The acupuncture points used in this group were the same acupoints selected in BA and EA groups, as well as the needle penetration procedure and timing, and the needle's size and characteristics. In the CA group, at the end of the body acupuncture session, the cupping was carried out with sterile glass cups , with size of 3 cm, at the affected side, in correspondence to the acupoints ST6 and ST7. According to the classical method of “retained cupping,” the practitioner used the flaming heating power to achieve suction; the glass cups were retained for about 1-2 minutes and then were detached. The cupping procedure was carried out repeatedly for 10 min.In all groups , the needles remained in place for 30 minutes and were then removed. The therapies consist of 8 sessions, administered over 4 weeks, twice a week. The needles were inserted by the same licensed acupuncturist and specialist in orofacial pain with 7-year experience (E. S.) in all treatment groups.T0: Baseline, before acupuncture treatmentT1: End of treatment, 4 weeks after T0 (after the last acupuncture session)T2: Short-term follow-up, 4 weeks after T1The symptoms evaluated for all patients were the following: temporomandibular joint (TMJ) pain, masticatory muscle pain, headache, and neck pain. Each type of pain was measured at the following times:The 0–100 verbal numeric scale (VNS) was used to measure pain self-assessment, with 0 indicating “no pain” and 100 “the worst imaginable pain.”At the same times T0, T1, and T2), all patients completed the following questionnaires, in order to evaluate the general pain-related disability and the impression of the treatment's effectiveness: Brief Inventory Pain (BPI) and Patients' Global Impression of Improvement (PGI-I) Scale [, and T2,The primary outcome of interest was the pain level and its variation over T0, T1, and T2 in all groups. The secondary outcomes were general pain-related disability (BPI) and the patient's impression of the treatment's effectiveness (PGI-I).p < 0.05.Data analysis was performed with SPSS (version 23) statistical processing software. Descriptive analyses and the Chi-square test were used to compare the patient characteristics. One-way ANOVA on ranks  was used to test differences at the same time interval between groups. Bonferroni-corrected post hoc tests were used for multiple comparisons. Friedman test was used to test changes over three time intervals in the same group. Comparisons of two time intervals were performed with the Wilcoxon signed-rank test. The level of significance was set at 376 patients were excluded according to the inclusion/exclusion criteria. The resulting study sample consisted of 90 patients, 28 males (31.1%) and 62 females (68.9%), with an average age of 46.93 years. The patient enrollment and intervention process followed the STRICTA  criteria and is shown in From the expected sample of 90 suitable patients, 30 were excluded from the analysis for discontinued intervention, mainly due to the impossibility in providing acupuncture treatments caused by COVID-19 pandemic in the period of March–November 2020 .p > 0.05) (The resulting study sample therefore consisted of 60 patients (20 patients in each group). The baseline characteristics of the study groups, including age and gender, are shown in  > 0.05) .No significant adverse effects were seen with respect to the procedure itself. A total of two adverse events were recorded: 12 in the EA group (4 needling pain after treatment and 8 hematomas), 10 in the BA group (3 needling pain after treatment and 7 hematomas), and 11 hematomas in the CA group. These adverse events could remit spontaneously within 1 week. No other side effects or complications were evident and all patients tolerated the treatment well.p > 0.05)  .p > 0.05).After the treatments (T1) and during the subsequent follow-up visit (T2), no significant differences were observed between the groups , except for TMJ pain in EA group and muscle pain in BA group  in all study groups  and particularly significant for headache  and neck pain (p < 0.001 in EA and CA groups). The results of this analysis and the exact p values are shown in Wilcoxon signed-rank test for the comparison of baseline (T0) and after treatment (T1) scores and follow-up (T2) scores resulted to be significant in all study groups for all types of pain considered , except for the variable mood (p=0.015). Interference values were significantly higher in BA and CA groups than in EA group for the variables “mood” and “relations with other people” after the treatment (T1) and at follow-up visit (T2)  and during the subsequent follow-up visit (T2), no significant differences were observed between the groups  .p < 0.05), except for the variable “walking ability”  in all study groups , except for the variable “walking ability.” It resulted to be particularly significant for the variables “general activity,” “mood,” and “sleep” (p < 0.001) in EA and CA groups. The results of this analysis and the exact p values are shown in Wilcoxon signed-rank test for the comparison of baseline (T0) and after treatment (T1) scores and follow-up (T2) scores resulted to be significant in all study groups for all variables considered  in order to evaluate any differences based only on the type of needle stimulation, not on the treatment principle or scheme. In light of the TCM principle of “treating with the least effort,” using the classical somatic acupuncture stimulation alone can be effective in improving the pain symptoms of the dysfunctional patient. Moreover, body acupuncture does not require any accessory tool/instrument unlike the other two methods used, resulting to be the most easily accessible and the most favorable in terms of cost/benefit. However, despite the lack of evidence of statistical significance, several differences can be highlighted among the results obtained in the three study groups, depending on the type of pain treated.Body acupuncture represents the classic and most common stimulation method of acupuncture and the most frequently mentioned for the treatment of orofacial pain. It involves the insertion of needles into the selected acupoints, which are manually stimulated by the operator. Zotelli et al. [Fernandez et al. [PT = 0.118). Furthermore, patients of the BA group reported statistically significantly lower average values of TMJ pain (PT = 0.004) overall, compared with patients of the CA group (PT = 0.047) and especially those of the EA group (PT = 0.247). Only one previous study by Corcos and Brandwein (1976) focused on the effects of body acupuncture treatment for pain related to the temporomandibular joint in 46 patients affected by rheumatoid arthritis and osteoarthritis. This study also pointed out the value of the body acupuncture method in improving TMJ pain [p < 0.001). Furthermore, both patients belonging to the EA and CA groups reported more significant results compared to patients treated with body acupuncture alone for all types of pain considered, except for TMJ pain.i et al.  verifiedz et al.  evaluateTMJ pain . The othcupping therapy to body acupuncture was found to be the most effective treatment method in the management of muscle pain. This evidence is consistent with the majority of systematic reviews and RCTs to date which suggest a favorable effect of cupping for pain, especially tension headache and musculoskeletal pain [Han et al. [p < 0.01). In line with the present study, the authors suggested that the combination of the two treatments leads to superior clinical outcomes, compared to the use of single medicated cupping therapy. However, it is difficult to make a comprehensive comparison with the results obtained in this research. The authors did not specify the type of pain treated or the TMD diagnosis of these patients; moreover, the cupping therapy procedure involved the addition of medicinal herbal substances.The addition of tal pain . The negtal pain . Han et n et al.  comparedTo our knowledge, this is the first study to analyze the effects of the classic technique of dry retention cupping combined with acupuncture on the most common types of pain associated with TMD. Given the positive results obtained, the need for further studies becomes evident to deepen and better define the therapeutic potential of this ancient medical practice in relieving pain related to TMD.Electroacupuncture is considered a particularly effective method of acupuncture for the treatment of persistent tissue and nerve injuries, chronic pain, and visceral pain, as addressed by several research studies conducted within the last decade [Kuo et al. [t decade , 22, 27.While evaluating the effectiveness of treatment methods for TMD, the psychological and emotional status of the patients, as well as their functioning in daily activities, should also be considered. Numerous studies highlighted the association between pain and some social, emotional, and psychological features influencing the quality of life of people affected by TMD –30. MoreStrengths of the present study include the randomized allocation of participants to the treatment groups, the follow-up recording, the differentiation of four types of TMD-related pain recorded, the evaluation of the participants' disability in common activities and quality of life by means of a validated questionnaire, and the evaluation of different methods of stimulation of acupoints using the same therapeutic scheme. Possible weaknesses of the study were the sample size and the duration of the acupuncture treatment. Acupuncture comprises several acupoint stimulation methods, treatment patterns, and timing, allowing the application of individualized therapies. Due to its versatility and special effectiveness in multifactorial diseases, acupuncture is particularly suitable for the treatment of TMD-related pain, which in turn is characterized by a very complex and varied symptomatology. For these reasons, despite the positive results obtained, we think that the patient sample size examined is too limited to present reliable results regarding the comparison of the effectiveness of three different acupuncture methods in reducing TMD-related symptoms. Furthermore, our results correspond to a single course of 4 weeks of therapy. Due to the tendency of TMD to become chronic, a prolonged course evaluation with additional long-term follow-up is necessary.Body acupuncture, electroacupuncture, and acupuncture combined with cupping therapy are all effective methods in reducing pain and pain interference with common activities and quality of life in patients affected by TMD.For the first time, the classical method of retained cupping is reported to be effective in the management of TMD-related pain, when combined with body acupuncture.Electroacupuncture reduces the interference of pain in patients' mood and sleep quality more effectively than body acupuncture alone or combination with cupping therapy.Further studies are needed to confirm the results obtained and to better define the eligibility of one of these methods in improving the complex symptomatology connected with TMD.


Due to lumbar spinal surgery is frequently accompanied with moderate-to-severe postoperative pain, it is necessary to find an effective postoperative analgesia for patients with this surgery. This study aimed to observe the analgesic effect of dexmedetomidine combined with ropivacaine erector spinae plane block (ESPB) used in posterior lumbar spine surgery.In this clinical trial, patients undergoing posterior lumbar spine surgery were recruited and randomly divided into two groups: intervention and control. The intervention group (Group E) received 0.375% ropivacaine with 1 µg/kg dexmedetomidine in a total of 20 ml for ESPB; the control group (Group C) received 20 ml ropivacaine 0.375% for ESPB. US-guided ESPB was performed preoperatively in all patients. Demographics, anesthesia time, surgery time, and ASA grade from the participants were recorded at baseline. The primary clinical outcome measures were 2-, 4-, 8-, 12-, 24-and 48-h visual analog scale (VAS) pain scores after surgery at rest and movement state. Other end points included opioid consumption, number of PCIA presses, flurbiprofen-axetil consumption, quality of recovery and pain management after surgery.P = 0.280). The mean anesthesia time was 152.55 (15.37) min in Group E and 152.60 (16.47) min in Group C (P = 0.986). Additionally, the surgery time was 141.70 (15.71) min in Group E compared to 141.48 (17.13) min in Group C (P = 0.943). In addition, we found that the VAS pain scores in the resting state during the postoperative period at 8–48 h were lower in Group E than in Group C. However, the VAS pain scores in the active state were lower in Group E at 12–48 h (P < 0.05). More importantly, the consumption of opioids and flurbiprofen-axetil after surgery was also lower in Group E (P < 0.05). Subsequently, we administered questionnaires on the quality of recovery and pain management after surgery that were positively correlated with the postoperative analgesic effect. It was worth affirming that the QoR-15 scores and APS-POQ-R questionnaire results were different between the two groups, further confirming that the combination of drugs not only could obtain an ideal analgesic effect but also had no obvious adverse reactions (P < 0.05).One hundred twenty patients were enrolled in the study (mean [SD] ages: Group E, 54.77 [8.61] years old; Group C,56.40 [7.87] years old; All the findings suggested that dexmedetomidine could significantly relieve postoperative pain and reduce the consumption of opioids in patients undergoing posterior lumbar spine surgery without obvious adverse reactions as a local anesthetic adjuvant. Further studies with larger sample sizes and different drug dosages may be useful in understanding the potential clinical benefits of dexmedetomidine. Enhanced recovery after surgery (ERAS) is a multimodal, multidisciplinary approach to promote postoperative outcomes by applying multiple evidenced-based interventions, which have been recently adapted for spine surgery at multiple institutions worldwide. While the role of ERAS protocols has been demonstrated in spinal surgery, the area of perioperative pain management requires more dramatic and complete improvements so that patients can benefit from implementing ERAS protocols after surgery .The key strategy to enhance perioperative pain management includes the use of a multimodal analgesia approach to reduce opioid consumption, decrease time in the hospital and improve patient satisfaction . UltrasoESPB is a paraspinal interfascial plane block that targets the ventral and dorsal branches of the spinal nerve. Local anesthesia is injected between the deep fascia of the erector spinae muscle and the vertebral transverse process during ultrasound-guided block . SeveralDexmedetomidine is identified as a highly selective short-acting alpha-2 agonist with sedative, anti-anxiety, inhibition of perioperative sympathetic excitation and hypnotic effects . AnotherThis study was approved by the Ethics Committee of Lanzhou University Second Hospital, Lanzhou, Gansu Province on 08/09/2020 (2020A-043), and the study was registered in the Chinese Clinical Trial Registry (ChiCTR2000038037). All of the enrolled patients had to sign a written informed consent form for this trial before surgery. A total of 120 patients aged 18–70 years old with ASA I–III who were scheduled for 1- or 2-level open posterior lumbar spinal fusion surgery under general anesthesia between January and June 2021 were enrolled in this study.The exclusion criteria included puncture site infection, abnormal blood clotting function, local anesthetic drug allergy, severe heart and lung disease, arrhythmia, liver and kidney insufficiency or mental illness, a history of chronic pain or a long-term history of taking analgesics. The rejection criteria included severe complications or accidents during the perioperative period or anesthesia, and those who did not cooperate well with the VAS scores.The included patients were randomly divided into two groups at a ratio of 1:1 using a computer-generated random number table. The results of the distribution were sealed in an opaque envelope and kept by the research administrator. On the day of the operation, the main researcher handed the envelope to the assistant anesthesiologist for the preparation of the test liquid.After all of the patients entered the operating room, pulse oxygen saturation, noninvasive arterial blood pressure, and electrocardiograms were routinely monitored. The patients were placed in the prone position and received midazolam 3 mg intravenously for preoperative sedation. The ultrasound probe was placed on the sagittal axis of the horizontal midline of the L3 vertebral body. The spinous processes were first observed, and then the probe was moved laterally to observe the transverse process and erector spinae muscle approximately 3 cm from the midline. Local anesthesia was injected between the deep fascia of the erector spinae muscle and the vertebral transverse process during ultrasound-guided block. An ultrasound-visible puncture needle was inserted from the cranial portion to the caudal portion using the in-plane technique, and the correct position of the needle was confirmed by injecting 2–3 ml of saline solution, after which 20 ml of 0.375% ropivacaine was administered. The same procedure was also performed on the opposite side. We performed injection at the L3 level because ESPB at this level can subsequently spread to levels L1-L5 , any of The patients were given full preoxygenation and induction of anesthesia was performed with intravenous 2 mg/kg propofol, 0.5 ug/kg sufentanil and 0.2 mg/kg cis-atracurium. The maintenance of anesthesia was established with 4–6 mg/kg/h propofol and 0.15–0.3 µg/kg/min remifentanil continuous pumping to maintain BIS values between 40–60. When necessary, 0.1 mg/kg cis-atracurium could be given for muscle relaxation during the operation. The drug continuous infusion dosage was adjusted to maintain HR and mean arterial blood pressure (MAP) within 80–120% of baseline. Hypotension (MAP < 80% of baseline) lasting for 3 min was managed with a bolus of 6 mg ephedrine. Bradycardia (HR < 45/min) was treated with atropine (0.25–0.5 mg).More importantly, posterior lumbar spine surgery was performed on all of the patients by the same surgical team and using the same techniques. Immediately after surgery, all of the patients were treated with 1 mg of neostigmine and 0.5 mg of an atropine antagonist muscle relaxant, and transported to the postanesthesia care unit (PACU) with tracheal intubation until tracheal extubation indications were reached.The same postoperative management protocol was adopted in both groups. First, patient-controlled intravenous analgesia (PCIA) was administered in the PACU by connecting an electronic infusion pump that consisted of hydrogen morphine ketone with 16 mg of ondansetron. The concentration of hydrogen morphine ketone was set to 0.05 mg/ml, the loading dose was 0.5 mg, the lockout interval was 15 min, and a 0.05 mg bolus was maintained for 48 h. Second, all of the patients received 50 mg of flurbiprofen-axetil intravenously after surgery, which could be repeated when the VAS score was greater than 5 postoperatively. Third, the patients with no apparent discomfort and modified Aldrete scores of 9 or more could be transferred to the ward. Finally, the patients were encouraged to perform functional exercises of straight leg elevation of the lower limbs after being fully awake. Lumbar and back muscle functional exercises were started 48 h after the surgery. On the fourth day, the patients were encouraged to move properly with the protection of a chest and waist brace.Postoperative care and evaluations were performed by a researcher who was unaware of the study groups. The primary outcomes were 2-, 4-, 8-,12-, 24- and 48-h VAS pain scores at rest and movement state after surgery . The movement state was defined as moving from the supine position to semiseated position. Secondary outcomes included opioid consumption, PCIA press times and flurbiprofen-axetil consumption. In addition, some questionnaires on the quality of recovery and pain management that were positively correlated with postoperative analgesic effect were administered after surgery. Patients were questioned at 24 h, 48 h, and 1 week postoperatively using the 15-item Patient-related Quality of Recovery Questionnaire (QoR-15). The quality of pain management was assessed using the revised American Pain Society Patient Outcome Questionnaire (APS-POQ-R).t test was selected, and the group allocation ratio was equal. Thus, we calculated that a sample of 48 patients would provide 96% power at a 2-sided α level of 0.05. Ultimately, we recruited 60 patients in each group for a total of 120 patients considering possible dropouts and incomplete follow-up.To determine the minimal sample size for the primary outcome, we treated the VAS score as a continuous variable and hypothesized a significant difference of 1 in the VAS score at rest at 12 h after surgery. Our pilot study showed a mean VAS score of 4.5 ± 0.8 at rest at 12 h after surgery for the control group and 3.4 ± 1.1 for the intervention group. Student’s t test. Nonnormally distributed variables are presented as the median ± quartiles (IQR) and were analyzed using the Mann–Whitney U test. Categorical variables are presented as numbers (percentages) and were analyzed by using the χ2 test. We considered P < 0.05 (two-tailed) statistically significant.Statistical analysis was performed using SPSS software, version 23.0 . The distribution of variables was evaluated for normality using the Kolmogorov-Smirnovand test and histogram test. Normally distributed variables are reported as the mean ± standard deviation (SD) and were analyzed using the independent samples Of the 138 patients assessed for eligibility, ten patients declined to participate, six patients withdrew after consent and two patients were excluded owing to protocol breaches. Consequently, a total of 120 patients were analyzed and completed the postoperative follow-up in the study  (Table P < 0.05)  Table . Opioid 5) Table .Table 1BP < 0.05)  ,  Figs. . Howeverly) Fig. , but at y), Fig. .Fig. 2CoP = 0.016 and median 116, IQR 111.25–120 vs. median 112, IQR 102–116.75; P = 0. 0.021). However, no significant difference was determined between the two groups in QoR-15 scores at POD7 (P = 0.190) . In addition, the percentage of time that patients experienced severe pain in the first 24 h was significantly different . The percentage of pain relief received from pain treatments was higher in Group E than that in Group C . In addition, the degree of pain interfering with or preventing activities and sleep was also different between the two groups (P < 0.05). In addition, the patient satisfaction scores were higher in Group E than in Group C . However, no significant differences in uncomfortable feelings and side effects were observed (P > 0.05) (Table As detailed in Table Lumbar spine surgery is frequently performed to relieve pain and provide functional improvement in patients with spinal stenosis and degenerative disc disease. During surgery, mechanical and thermal trauma can cause muscle ischemia and damage to nerves innervating the paraspinal muscles. Therefore, it is often characterized by severe and diffuse pain in the postoperative period , 23. ERATo the best of our knowledge, clinical trials have previously shown that various adjuvants for local anesthetics have significant effects, but there have been few studies of the use of dexmedetomidine as a local anesthetic adjuvant in ESPB, and none have satisfactorily assessed the quality of postoperative recovery . In a prDuring the course of this study, adding 1 µg/kg of dexmedetomidine to ESPB did not cause significant fluctuations in MAP or HR. In addition, there was no significant difference in the incidence of nausea, vomiting, dizziness or other adverse reactions between the two groups. However, the results did not indicate that any dose of dexmedetomidine was safe for perineural injection. In a previous study, the researchers found that adding 100 µg of dexmedetomidine to local anesthetic resulted in a significant decrease in blood pressure and HR during the first 2 h after surgery . FurtherFurthermore, we chose the QoR-15 score and APS-POQ-R questionnaire as the secondary outcomes, mainly because the Standardized Endpoints in Perioperative Medicine initiative stated that one or more of six recommended endpoints should be considered in clinical trials evaluating patient comfort after surgery . One of Our study demonstrated that a single injection of ropivacaine provides sensory block for 6–8 h, and postoperative pain often increases opioid consumption and causes opioid-induced side effects, including respiratory depression, nausea and vomiting , 34. How2A-ARs are the mechanism of dexmedetomidine in the treatment of peripheral nerve block pain [However, the main mechanism associated with the action of dexmedetomidine in improving blockade efficacy remains unclear. Previous studies have included the following three hypotheses. First, dexmedetomidine causes vasoconstriction which delays absorption of the local anesthetic and prolongs the effect of local anesthetics , 38. Secock pain .Our study had several limitations. First, the assessment methods of pain levels and sensory blockade were limited to subjective sensation of pain and cold. Second, the study was a small, randomized, double-blind trial closely integrated with clinical application. Further large-scale trials are needed to evaluate the clinical efficacy of dexmedetomidine as a local anesthetic adjuvant. Finally, there have been few studies of the mechanism of peripheral dexmedetomidine in ESPB. Therefore, it is necessary to conduct in-depth studies of the preclinical toxicity and clinical application of dexmedetomidine as a local anesthetic adjuvant to clarify its mechanism of action and safe optimal doses to provide a maximum benefit while minimizing side effects in ESPB.Dexmedetomidine, as an adjunct to ropivacaine used in ESPB, can prolong sensory block time, effectively control postoperative acute pain, reduce the need for remedial analgesia, and improve postoperative recovery quality and patient satisfaction. Because of the safety and efficacy of dexmedetomidine, we recommend its widespread use in peripheral nerve block.


Our goal was to determine whether implementation of a prescription drug monitoring program (PDMP) altered emergency department (ED) opioid prescription rates overall and in patients of different pain severities.We conducted this single-center, retrospective review at an academic ED. The study examined patients discharged from the ED who received opioid prescriptions, before and after the state’s implementation of a PDMP . The monthly rate was a ratio of the patients given ≥ 1 opioid prescription to the ED patients with a numeric pain rating scale (NPRS) > 0. We performed an interrupted time series analysis on each demographic.The overall ED opioid prescription rate decreased from 51.3%  to 47.9% . For males, this decreased from 51.1% to 46.7% (P < 0.0001), while in females it did not significantly change (51.6% to 49.7% [P = 0.0529]). For those with mild pain, the rate increased from 27.5% to 34.3% (P < 0.0001), while for those with moderate pain, it did not significantly change (42.8% to 43.5% [P = 0.5924]). For those with severe pain, the rate decreased from 66.1% to 59.6% (P < 0.0001).We found that PDMP implementation was associated with an overall decrease in opioid prescription rates, and that patients with mild pain were prescribed opioids more often while severe pain patients were prescribed opioids less often. Rates of opioid prescription and opioid-related deaths in the United States have quadrupled over the past three decades.In analyses of the distribution of opioid prescriptions, prescriptions in the ED are often carefully scrutinized.With access to the PDMP database, emergency physicians can acquire information regarding a patient’s past controlled substance prescriptions and their frequency. Physicians can then tag individuals who are at high risk for misuse of opioid prescriptions. The primary objective of the implementation of PDMPs is to reduce the mortality and misuse of both prescription opioids and illicit opioids.23Current literature examining opioid prescription rates after PDMP implementation fail to show consistent results, likely due to program variability from state to state.We conducted this single-center, retrospective review at an academic, suburban, tertiary ED. The overall study examined patients discharged from the ED who received opioid prescriptions that were recorded in the electronic health record (EHR), before and after the state implemented a PDMP system. In Pennsylvania physicians are required to query the PDMP database whenever they are prescribing an opioid or benzodiazepine. They are also required to query the PDMP if they believe that the patient may be a high-risk misuser of prescription drugs. This study was approved by the institutional review board.We retrospectively extracted data from the EHR from December 2014–May 2018. Any patient who met the inclusion/exclusion criteria was included in the study. Inclusion criteria were as follows: the patient had to have been triaged and treated by a physician in the ED during the given timeframe; prescribed at least one opioid prescription at the end of their visit; discharged directly from the ED; and to have had a rating greater than zero on the initial numeric pain rating scale (NPRS). We excluded patients if they arrived to the ED outside of the timeframe of the study, were admitted to the hospital for any period of time, had a documented NPRS of zero, did not have one of the study variables documented in the EHR, and were not prescribed an opioid at the end of their visit. A baseline patient total was also extracted from the EHR for each month of the study with the same inclusion/exclusion criteria, with the exception of a required opioid prescription. This data, which served as the denominator in our primary outcome measure, provided the total number of ED patients who presented with any level of pain, but were not necessarily given an opioid prescription at the end of their visit. In addition, if the same patient visited the ED multiple times during the study period and met inclusion criteria, they were considered as separate patients.What do we already know about this issue?Despite the seeming downtrend in opioid prescribing, concern remains for misuse.What was the research question?Does implementation of a prescription drug monitoring program (PDMP) alter ED opioid prescription rates overall and for patients with different pain severities?What was the major finding of the study?Post-PDMP, opioid prescribing decreased overall for males and for patients in severe pain, but increased for those with mild pain.How does this improve population health?Given the prevalence of opioid misuse, implementing a PDMP could potentially decrease opioid prescribing and thereby also reduce misuse.We extracted the following data from the EHR: age; gender; date of encounter; and initial NPRS score (ranges 0–10). Pain scores were separated as follows: 1–4 (mild); 5–6 (moderate); and 7–10 (severe). These stratifications were based on a previous study that found these ranges to be the most accurate for each qualitative measure of pain severity based on a large-scale community survey.P values no higher than 0.05. All analyses were performed with SAS software, version 9.4 .We performed an interrupted time series analysis to determine whether the PDMP intervention resulted in a change in the opioid prescribing rates. The periods before and after the PDMP implementation constitute the two segments of the regression model. We used the Durbin-Watson statistic to detect auto-correlation. Exploratory subgroup analyses were performed on gender, age, and pain score. Descriptive statistics were generated including means, medians, and standard deviations for continuous variables; frequency tables and odds ratios were calculated for categorical variables. We used Pearson’s chi-square test to compare overall rates before and after the PDMP implementation. The 95% confidence intervals around reported estimates reflect 0.025 in each tail, or A total of 27,390 patient ED visits initially meeting study criteria were extracted from the EHR between the full time period. Of those, 587 patients were excluded by the statistician and the principal investigator due to duplicate reports of the same visit, incomplete data, or incorrectly documented data. This resulted in 26,803 patient ED visits meeting study criteria, which were then reviewed. The patients were then divided into two separate cohorts based on date of encounter: pre-PDMP (December 2014–August 2016) and post-PDMP (September 2016–May 2018). Some suggest the primary goal of the PDMP is to curb the opioid epidemic by allowing physicians to detect patients who may be prescribed opioids too frequently.Ultimately, the PDMP is believed to have a multifaceted function in diminishing the opioid epidemic. Although the primary purpose of the PDMP is to curb the number of opioid prescriptions, current literature has found that the implementation of the PDMP also increases conscious awareness of physicians regarding opioid prescribing and aids in identification of patients with opioid use disorder, allowing for timely referral to interventional programs.29The varying trends in each study can likely be attributed to differing protocols at each institution, contrasting clinical presentations to each health system, and ultimately varying state guidelines regarding the use of the PDMP.In addition, we also found distinct changes in prescribing habits within different pain cohorts. With the PDMP implementation, patients experiencing mild pain were prescribed opioids more frequently while patients with severe pain were prescribed opioids less frequently. To our knowledge, no other studies have performed interrupted time series analyses after PDMP implementation in the ED on mild, moderate, and severe pain cohorts. Similarly, literature is sparse regarding the effect of a PDMP implementation on patients presenting with different pain severities. The changes we noted could have been due to the fact that patients with severe pain more often present with chronic pain and, thus, more typically already are being prescribed opioids in the PDMP. In addition, it has also been noted in current literature that drug-seeking behavior in the ED is typically associated with higher reported pain severity on the NPRS scale.We also found that males were significantly less likely to be prescribed opioids in the ED after PDMP implementation, while there was no change for prescribing to females. In addition, we found that all three age cohorts  between ages 18 and 63 years were significantly less likely to be prescribed opioids in the ED after PDMP implementation. This differs from other studies that found no differences in opioid prescribing with regard to age or gender after the implementation of a PDMP.There are limitations to our study. It is important to note that it is not possible to attribute the implementation of the Pennsylvania PDMP as the sole cause for reduction of overall opioid prescribing trends. The data can only show time-dependent correlation, not causation. Given that in the current study, opioid prescription rates were already downtrending prior to the studied intervention, it is possible that other factors may have played a role, including expeditiously increasing awareness regarding the opioid epidemic and guidelines to curb it, the release of the US Centers for Disease Control and Prevention Guidelines for Opioid Prescribing in March 2016, and institutional changes that may have coincided with the implementation of the PDMP. Also, because our data relies on the accuracy of pharmacists and physicians entering data into the EHR and the PDMP, it is possible that errors occurred in the process.The current study also relies on the fact that all patients with a complaint of pain had a pain score documented in the EHR; moreover, if a patient did not have a pain score documented, they were excluded from the study, thereby altering the accuracy of our opioid prescription rate. Also, although Pennsylvania requires a prescriber to query the PDMP before prescribing an opioid, we were not able to capture compliance rates in this study. It is important to note, however, that at the time of the study, the institution did not have PDMP data automatically imported into the patient chart. In addition, as this study was only conducted at a single hospital in Pennsylvania, it may not be easily generalizable.While state and institutional guidelines vary, this study does provide new data regarding the effect of the PDMP on specific pain cohorts. It is also important to note that the pain scores collected were the initial pain score in the ED, which often coincided with the triage pain scores. Therefore, some of the ED treatments likely may have improved patients’ pain during their visits. Lastly, we were unable to analyze specific medications, and therefore the dosage  and number of pills, that were prescribed to patients in the ED. This data would have provided important information that could have aided in targeting the reduction of certain opioid prescriptions.Based on this analysis of opioid prescriptions pre- and post-PDMP implementation, we found that the implementation of the PDMP was associated with an overall significant decrease in opioid prescription rates in this ED. In addition, we also found that after the implementation of the PDMP, patients with mild pain were prescribed opioids more often, while those with severe pain were prescribed opioids less often.


Values of pain and function (shoulder pain and disability index (SPADI) questionnaire, complemented by the numeric pain rating scale (NPRS) and disabilities of the arm, shoulder, and hand (DASH) questionnaire) were assessed at the initial, 4-week, and 2-year follow-up and compared within and between. There were significant differences in pain and function improvement between the initial and 4-week assessments. There were no differences in the values of DASH 1st part and SPADI between the 4-week and 2-year follow-up. There were no differences between groups at the baseline and long-term, except for DASH 1st part and SPADI (p < 0.05). Only 29 patients (15.8%) had a recurrence episode at follow-up. These results provide valuable information on the positive results of the protocol in the short- and long-term.Current clinical practice lacks consistent evidence in the management of scapular dyskinesis. This study aims to determine the short- and long-term effects of a scapular-focused exercise protocol facilitated by real-time electromyographic biofeedback (EMGBF) on pain and function, in individuals with rotator cuff related pain syndrome (RCS) and anterior shoulder instability (ASI). One-hundred and eighty-three patients were divided into two groups ( The rotator cuff related pain syndrome (RCS) ,2 and anResearch investigating the scapular orientation and kinematics in RCS compared to asymptomatic controls concluded that no irrefutable relationship could be found between the scapula orientation and RCS . HoweverWhen it comes to shoulder instability, there is limited research in the management to guide therapists . For traSeveral randomized studies ,18,24 haHowever, to date, the scapular-focused exercise incorporated in research interventions has been quite varied with a lack of clarification about the intensity, frequency, and progression of exercises and a lack of explicit objective scapular related criteria for the success and progression of exercise ,25. MoreThe main objective of this study was to describe the short- and long-term effects of a scapular-focused exercise protocol supported by real-time EMGBF on the level of pain and function in individuals with shoulder dysfunctions. Additionally, scapular neuromuscular activity and control, ROM, and glenohumeral flexor and abductor isometric muscle strength (GMS) were assessed to explore the mechanisms of recovery.After 4-weeks of treatment, the protocol would lead to an amelioration in both groups in pain and function (decrease in the shoulder pain and disability index (SPADI)  levels wPrimary outcome ameliorations (pain reduction and function improvement) made at the 4-week assessment would be retained at the 2-year assessment in both groups.It was hypothesized that:A prospective cohort was developed to implement the scapular-focused exercise protocol, with initial, 4-week, and 2-year follow-up assessments.n = 117) and ASI group (n = 66). All patients had a prior consultation with an orthopaedic physician who made the diagnosis and recommended physiotherapy. The mean (±standard deviation) age for the RCS group was 41.1 (±12.2) and for the ASI group 26.7 (±10.3) years. Patient symptoms originated mostly from overuse in the RCS group (59.0%) and trauma in the ASI group (48.5%). Most patients in both groups were in the chronic stage of the condition (length of symptoms for more than 6 weeks) (81.2% for the RCS group and 71.2% for the ASI group). Sample demographics and clinical information are presented in From 213 patients recruited consecutively from an outpatient orthopaedic clinic, 183 were included and 30 unable to commit to the schedule of treatments were excluded before commencing. These 183 patients were divided into two groups according to the diagnostic categorization: RCS group .Descriptive statistics (means and frequency) were used to characterize the groups and variables’ distribution. The Mann-Whitney U test and Wilcoxon signed-rank test were used to compare the quantitative outcomes. Fisher’s exact test and McNemar exact test were used to compare the qualitative outcomes. Regarding the missing values (present only at follow-up) a complete-case analysis approach was adopted, assuming the missing data is completely random and unrelated to any of the variables involved in the study. The significance level was set at p < 0.05) but none in any of the secondary outcome measures , decreased scapular neuromuscular activity and control , decreased ROM and GMS. There was a difference in the scores of SPADI and DASH 1st and 3rd parts (measures .p < 0.05) in both groups and the pain and function MCID values were met. Differences were found between the groups in the outcome SPADI, NPRS, and DASH 1st part at this short-term assessment (p < 0.05)  .p < 0.05)  .p < 0.05). At the 2-year follow-up, the two groups were only different in the levels of SPADI and DASH 1st part  patients were unable to return for an objective re-assessment and instead were contacted by either email or phone to answer the outcomes not requiring their presence, seven (3.8%) patients were unreachable, 29 (15.8%) patients reported returning to physiotherapy between the treatment protocol and follow-up to seek new treatment due to the same shoulder problem (recurrence), and 23 (12.6%) were not included in the 2-year follow-up as they reported having had new traumatic incidents unrelated to their treatment in the study that resulted in them seeking further health care services .Repeated measures for time were unfeasible due to the non-normal distribution of outcomes. The power analysis by t-tests was computed for pain and function outcomes, considering the difference between two dependent means. The results obtained showed an excellent power for all variables (0.99 < d < 1.00), given the sample size of 183 participants. These results boost confidence in the outcomes reported, reinforcing the relevance of the intervention and assessment methods on the recovery efficacy of these patients, between their initial and short-time assessments and between their short-time and long-term assessments.In this study of the measures taken at the initial assessment, the RCS and ASI groups were different for age, and the outcome of SPADI, DASH 1st, and 3rd part, with higher mean age and higher SPADI and DASH disability scores for the RCS group. Older patients usually present with worse function levels than younger patients ,29. The The within-group analysis, comparing results between the initial and 4-weeks (short-term) assessments, showed that clinically meaningful changes were achieved for pain and function over time in both groups. Both outcomes reached their predefined MCID and the other outcomes presented meaningful improvements. While both groups improved significantly, it was not the diagnostic category that determined the specific exercises, rather it was an assessment of the patients’ movement/control impairments. This is consistent with the view that, even when following a protocol or recommended guidelines, the management should be tailored to the patients’ pain and disability presentations rather than the hypothesized clinical diagnostic categorization ,56.Two years after discharge, despite a slight loss in the outcomes, the scores of SPADI, NPRS, and DASH 1st part for the ASI group and the scores of SPADI, DASH 1st, and 3rd part for the RCS group as well as the results of ROM and GMS for both groups were not different, demonstrating that the protocol of good results was not temporary. For the outcome scapular neuromuscular activity and control, only the SSAO component maintained the 4-week results through to the long-term. The SSNC and dynamic scapular alignment components presented differences.For pain and function, the results of SPADI, NPRS, and DASH at 4-weeks were very good for both groups. NRPS at the short-term had a mean of 1.58 ±1.29) for the RCS group and 0.91 (±1.16) for the ASI group, which is better than most studies incorporating scapular exercise to treat RCS or ASI associated shoulder pain and dysfunction  for the ,28,29,34The initial results of SSNC of decreased activity in LT and SA muscles corroborated the presupposition that shoulder dysfunctions comprise an alteration in the scapulothoracic stabilizer function , consistConcerning SSAO, half of the sample in this study already presented a feedforward mechanism  rather tContemporary neuroscience and motor control theory hold that pain alters motor patterning/control variably in response to the individual’s conscious and unconscious perception of threat, leading to changes in movement and motor function to provide protection from further pain, injury or threat ,64,67. SThe dynamic scapular alignment showed significant differences between the initial and 4-week assessments with very good results, but around 40% of the patients lost their gains at the follow-up, despite the great results of the pain and function, SSAO, ROM, and GMS outcomes. This supports the previous literature challenging the relationship between scapular alignment and RCS ,17,68. WHigh recurrence rates are common in shoulder dysfunctions, particularly in sport activities . At a 3-The results of this study support other research ,71,72,73Both 1st and 2nd hypotheses were confirmed successfully with a reduction of pain and an increase of function with differences at the short-term assessment, and no differences between the short- and the long-term. Some limitations should be considered that restrict the generalizability of results: (1) No direct cause-and-effect relationship can be drawn from this protocol and these results as it did not include a control group. Further studies are needed to assess the effectiveness of this protocol against other rehabilitation approaches and clarify the contribution of EMGBF and possibly the kinematic feedback ,75; (2) The presented findings suggest that a well-described scapular-focused exercise protocol, with the aid of real-time EMGBF feedback and home management, can reduce pain and increase function, as well as scapular neuromuscular activity and control, ROM, and GMS in patients with shoulder dysfunctions in the short-term. At the long-term, it appears to maintain the gains of pain and function, and the gains of SSAO, ROM, and GMS, but not for SSNC and dynamic scapular alignment. The inclusion of both ASI and RCS impairment associated groups adds evidence to the limited body of knowledge on the effect of physiotherapy on these types of shoulder dysfunctions.


We report a case of spondylodiscitis in two non-sequential segments of the lumbar spine that was unresponsive to antibiotic treatment instituted and guided by results of blood and urine cultures.A 70-year-old female was admitted to our hospital with complaints of adynamia, low fever, and severe lower back pain that caused difficulty in mobilizing the lower limbs. Spinal tomography and magnetic resonance imaging (MRI) of the lumbar spine suggested L2L3 and L5S1 spondylodiscitis. After an initial period of improvement, the patient’s condition began to deteriorate again four weeks after initiating the antibiotic therapy. We then opted for surgical treatment through a full-endoscopic transforaminal route, with the aim of collecting intervertebral discs material and performing debridement. After the procedure, the patient experienced immediate relief from the pain and was able to stand and walk without assistance. Cultures from disc fragments showed different bacterial species than that found in the first examination.The endoscopic approach allowed less tissue damage, debridement of the disc, collection of multiple fragments, thereby facilitating the best antibiotic therapy, and shortening the duration of hospital stay. The term "spondylodiscitis" refers to the primary infection of the intervertebral disc by a pathogen and secondary osteomyelitis of adjacent endplates, usually occurring in conjunction with each other. In developed countries, the incidence of spondylodiscitis varies between 1:100,000 and 1:250,000. This condition is a major manifestation of hematogenous osteomyelitis in patients over 50 years of age and represents approximately 3%-5% of all osteomyelitis cases [From the point of view of diagnosis, infections involving the intervertebral disc are usually challenging. This is because the onset is often sudden, without any symptoms. In addition, there are difficulties in identifying the causative agent that is necessary for an adequate treatment. A delay in early diagnosis and instituting therapy may lead to instabilities, deformities, sepsis, and, in some cases, even death .Spinal infections can occur spontaneously in patients who are immunocompromised because of the hematogenous dissemination through an infectious focus or following surgical procedures, which has been increasing progressively due to the greater number of procedures performed on the spine. The target for the treatment of spondylodiscitis involves treating the infection, neurological protection, and maintaining the structural alignment of the spine .Approaches for detecting the causative organism include blood and urine culture and acquisition of image-guided tissue. However, the rate of identifying the causative pathogen is reported to be variable .This study aimed to report a case of spondylodiscitis in two non-sequential segments of the lumbar spine using a full-endoscopy technique, which facilitated the identification of the causative agent without causing any harm to the lumbar spine stability.A 70-year-old female was admitted with complaints of adynamia, low fever, severe lower back pain, and difficulty in mobilizing the lower limbs due to the associated pain. On clinical examination, she was pale, hypohydrated, with a low fever, and in an antalgic position due to the severe pain. She was unable to adopt a standing or sitting position because of the severe intensity of the lumbar pain. The patient reported having chronic renal failure, non-dialysis, systemic arterial hypertension, and diabetes mellitus.Laboratory tests on admission revealed leukocytosis and elevated C-reactive protein (CRP) levels. Blood and urine samples were collected, and antibiotic treatment with vancomycin (500mg IV every 12 hours) was started empirically.Enterococcus faecalis, she was started with meropenem (1g IV every 12 hours) for four weeks initially, according to clinical and laboratory response. Though the antibiotics along with hyperbaric oxygen therapy initially improved the infectious condition, the low back pain persisted. After an initial period of improvement, she developed a low-grade fever and worsening of laboratory parameters despite four weeks of antibiotic therapy. After discussing the case, an endoscopic approach was indicated at both lumbar levels to collect tissue and clean the disc space.She underwent spinal tomography Figure  and magnThe patient underwent a transforaminal approach, with an inside-out technique, under local anesthesia and conscious sedation in the prone position. A spinal endoscope  with a 30-degree optic was used for the entry point to the L2L3 space approximately 8 cm from the midline and to the L5S1 space 10 cm from the midline, and a spinal needle was inserted into the target disc through Kambin’s triangle Figure .Stenotrophomonas maltophilia, which was different from that isolated in the first examination, and the patient was started on trimethoprim/sulfamethoxazole (400mg IV every 12 hours). She was discharged from the hospital after six weeks of treatment with preserved functional capacity. She returned for a follow-up of 30 days, with no complaints of pain or walking without assistance.After the surgical procedure, the patient presented immediate relief from the pain, probably by reduction of nociceptive stimulus and resolution of spinal canal stenosis and the compression of spinal roots, and was able to stand and walk without any assistance. Table Spondylodiscitis is an uncommon disease, and its diagnosis is often difficult due to non-specific initial signs and symptoms. This leads to a delay in diagnosis and subsequently in treatment too .The treatment of spondylodiscitis aims to cure the infectious condition, restore and preserve the structure and stability of the spine, facilitate recovery from neurological deficits, and direct appropriate pain therapy .A number of approaches such as conservative treatment, traditional open surgery, and minimally invasive surgery exist for treating spontaneous spondylodiscitis. Traditionally, the conservative approach comprising the use of broad-spectrum antibiotics and bed rest was considered adequate for the treatment . In addiHyperbaric oxygen therapy comprises the administration of 100% oxygen at pressures greater than that of the atmosphere and is a recognized treatment for a number of disorders, such as gas gangrene, severe necrotizing soft tissue infections, and chronic refractory osteomyelitis . This thThough open surgery  with or without instrumentation have been documented to yield good results, they are often associated with relatively high complication rates .As shown by Wu et al., and recently in infectious processes, without severe neurological symptoms ,9-11, enIn the present case, due to the need for approaching two non-sequential levels, endoscopy was chosen. This was because the procedure is performed routinely in our clinical, is minimally invasive, and permits the possibility of performing an exhaustive cleaning of the disc space and structural maintenance of the lumbar spine.Ito et al. used the posterolateral endoscopic technique on 15 patients with pyogenic spondylodiscitis in the thoracic or lumbar spine. The authors reported that all patients had immediate pain reduction after the surgery, and infections were successfully treated. They concluded that endoscopic debridement via posterolateral and continuous irrigation results in satisfactory clinical outcomes in patients with comorbidities and pyogenic spondylodiscitis .In another study that included 60 patients with spondylodiscitis treated with an endoscopic procedure, all patients experienced rapid pain relief after surgery. Furthermore, there were no changes in sagittal alignment, and pathogens were identified in around 77.27% of patients from samples collected before the use of antibiotics. CRP and erythrocyte sedimentation rate values significantly decreased three months after the endoscopic surgery. Two patients in the series required a new endoscopic approach, and no complications related to the procedure were reported .Spondylodiscitis at two non-adjacent levels can be a challenge for surgical treatment, as it requires greater exposure to approach both levels. Access to disc infections by endoscopy via the transforaminal route offers the possibility of a direct approach to the disc space, with several advantages such as minimal tissue damage, possibility of using local anesthesia and conscious sedation (required for patients with multiple comorbidities), and greater accuracy in identifying the causative pathogen, without modifying the posterior structures of the spine.