Dual-energy X-ray absorptiometry is rarely utilized in the clinical care of patients with complex regional pain syndrome, but may be useful for the non-invasive determination of regional bone fragility and fracture risk, as well as muscular atrophy and regional body composition. This is the first report in the literature of complex regional pain syndrome and musculoskeletal co-morbidities in an athlete, and is the first to focus on dual-energy X-ray absorptiometry for the clinical assessment of complex regional pain syndrome.2 at the time of presentation. Despite severe complex regional pain syndrome in the left limb and long term use of a wheelchair, the patient participated in high-performance powerlifting. Dual-energy X-ray absorptiometry revealed marked unilateral differences in bone strength and lean mass between the affected regions and the contralateral regions. Low bone mineral density for age was found in the left hip, with Z-scores ranging from −2.2 to −3.0, and the patient had previously suffered two fractures. Bone density Z-scores in the right hip and legs were normal.In this report, we describe the case of a 29-year-old Caucasian man with type 1 complex regional pain syndrome. His body mass index was 29.4kg/mDual-energy X-ray absorptiometry is a valuable tool for the clinical investigation of musculoskeletal health in patients with complex regional pain syndrome. Regional osteoporosis in complex regional pain syndrome patients is complicated and should be investigated and monitored. Physical activity is possible for some complex regional pain syndrome patients, depending on the type of exercise and the region affected, and it may protect bone density and strength at non affected skeletal sites. Complex regional pain syndrome (CRPS) can be triggered by peripheral trauma, fracture, surgery, or spontaneously and causes significant functional morbidity. The International Association for the Study of Pain (IASP)  defines Of the CRPS comorbidities, region-specific osteoporosis and muscle hypotrophy may also be considered as objective indicators of the disease, although there is a lack of published data on this topic. Osteoporosis is a systemic, skeletal disease characterized by low bone density and microarchitectural deterioration of bone tissue with a consequent increase in bone fragility. Osteoporotic fractures are the clinical endpoints of bone fragility and carry significant mortality and morbidity. Such musculoskeletal entities associated with CRPS  are likeA 29-year-old Caucasian man presented to our institution for DXA investigations. He met the IASP criteria for CRPS and was medically diagnosed with type I CRPS. His symptoms associated with CRPS were first reported at the age of 10 years following orthopedic surgery to the left hip. That surgery was initiated after he had been diagnosed with Calve-Perthes disease at the age of 9 years. Rehabilitation from the surgery was unsuccessful, and he remained wheelchair-bound thereafter because of inability to move his left leg, accompanied by severe, localised pain. There was blue discoloration to the affected limb , and the patient had abnormal hair and toenail growth as well as swelling. His other chronic complaints included severe pain while taking a shower, bruising, and insomnia due to pain. Numerous orthopedic and pediatric physicians confirmed that his Perthes disease was no longer a problem following surgery. The patient had been diagnosed with CRPS at age 13 years. He had fractured his left fifth metatarsal at age 17 years, and he fractured to his left patella at age 24 years. Sensitivity tests conducted at a pain management unit in 2011 revealed marked mechanical allodynia induced by the lightest monofilament (finer than a hair) and hypersensitivity to a pinprick with lasting tingling in the left leg. He received different methods of pain treatment, including guanethidine blocks, which helped only initially for approximately one week. Subsequent treatments included opioids and spinal cord stimulation. Combinations of drugs were prescribed for neuropathic pain, but produced little benefit. The patient had also taken antidepressants (fluoxetine hydrochloride) for several months at age 17 years. At the time of our assessment, the patient was taking amitriptyline, co-codamol and diclofenac.The long-term symptoms and comorbidities of CRPS can often lead to inability to perform activities of daily living, which usually means that participation in physical activity and high-level sports is not possible. Our patient engaged in regular upper-body resistance exercise training and performed competitively at the international level. He had been participating in the competitive sport of powerlifting for more than three years, despite his severe CRPS symptoms.2); exclusive of soft-tissue spaces) and cross-sectional moment of inertia results were obtained using HSA. The duration of the total body scan was 7 minutes, and the total hip scan, 2 minutes. The scans were analyzed using the Lunar enCORE software version 13.6 .The patient was measured while wearing lightweight clothing and no jewelry. His height was measured to the nearest millimeter using a stadiometer , and his body weight was recorded to the nearest 0.1kg with calibrated electronic scales (seca United Kingdom). DXA was performed using a fan-beam Lunar iDXA imager  in standard mode. The machine’s calibration was checked and passed on a daily basis prior to the scanning session using the GE Lunar calibration phantom. There was no significant drift in calibration prior to the scanning session. For the total body scan, the patient was placed in the supine position on the scanning table with his body aligned with the central horizontal axis. His arms were positioned parallel to, but not touching, the body, with his legs fully extended. His feet were not secured with the usual support so as not to cause him any distress. For the total hip scan, the patient was again positioned supine on the scanning table. His arms were placed across his chest, and his feet were placed on either side of the dual femur positioning support. His feet were not strapped, but rather were inwardly rotated to obtain an optimal scan image. The total hip scan also enabled hip structural analysis (HSA) to gain information on the structural geometry and strength of the patient’s left proximal femur. Section modulus, cross-sectional area  through immobilization due to CRPS, the rate of loss, as well as any possible systemic factors. Although it has been suggested that patients with osteoporosis are more susceptible to CRPS , the finDXA is a valuable tool for the clinical investigation of musculoskeletal health in patients with CRPS. Regional osteoporosis in CRPS patients is complex and should be investigated and monitored. Therapy aimed at improving bone density in affected patients should be considered. Physical activity is not completely out of the question for CRPS patients, depending on the type of exercise and the region affected, and may protect bone density and strength at non-CRPS sites.Written informed consent was obtained from the patient for publication of this case report and any accompanying images. The patient’s sports coach also provided informed consent, and both the patient and his coach were consulted throughout the case report preparation. A copy of the written consent is available for review by the Editor-in-Chief of this journal.BMC: Bone mineral content; BMD: Bone mineral density; BMI: Body mass index; CRPS: Complex regional pain syndrome; CSA: Cross-sectional area; CSMI: Cross-sectional moment of inertia; DXA: Dual-energy X-ray absorptiometry; HSA: Hip structural analysis; IASP: International Association for the Study of Pain; LTM: Lean tissue mass.The authors declare they have no competing interests.KH collected, analyzed and interpreted the patient DXA data. KH and MJ reviewed the patient’s medical history and prepared the manuscript. Both authors read and approved the final manuscript.KH is a Senior Research Fellow specializing in musculoskeletal physiology and medical imaging. MJ is an expert in the field of pain and analgesia and is a neurophysiologist.


Fibromyalgia may coexist with other clinical conditions such temporomandibular disorders (TMD). Temporomandibular disorder is a term embracing clinical disorders that involve the masticatory musculature, the temporomandibular joints, and associated structures.The purpose of this study was to assess the prevalence of orofacial symptoms and signs in patients with juvenile fibromyalgia.Twenty-eight consecutive patients (22 girls) who presented to our outpatient pediatric rheumatology clinic and fulfilled the ACR criteria of fibromyalgia were included in this study. All patients underwent a rheumatologic examination performed by a pediatric rheumatologist, and an orofacial examination performed by a single dentist at the same data. The patients were interviewed according to a standardized questionnaire concerning the presence of orofacial pain and functional impairment and were submitted to a clinical evaluation following a structured protocol.The mean age at the evaluation was 13 years (range 8- 18 years) and the mean follow-up time was 3.3 years (0.3 to 12). Orofacial symptoms were reported in 14 (50%) of patients. The most common subjective symptoms were impaired ability with chewing (50%), pain in function (28.6%), and pain at rest (17.8%). We found that the vast majority of our patients (89.3%)reported pain on palpation in at least two of six sites in the orofacial region, but only 7 (25%) had pain during mandibular movements, and nobody had restrictions to open their mouths 40 mm or more.Although palpation of the orofacial region is not included in the diagnostic criteria for fibromyalgia, a large number of juvenile patients presented with pain on palpation in this region. This study suggests the need for interdisciplinary strategies to effectively diagnose and treat this chronic condition.None declared.


Symptomatic cervical intervertebral disc herniation (IDH) presenting as neck pain accompanied by arm pain is a common affliction whose prevalence continues to rise, and is a frequent reason for integrative inpatient care using complementary and alternative medicine (CAM) in Korea. However, studies on its long term effects are scarce.A total 165 patients with cervical IDH admitted between January 2011 and September 2014 to a hospital that provides conventional and Korean medicine integrative treatment with CAM as the main modality were observed in a prospective observational study. Patients underwent CAM treatment administered by Korean medicine doctors (KMDs) in accordance with a predetermined protocol for the length of hospital stay, and additional conventional treatment by medical doctors (MDs) as referred by KMDs. Short term outcomes were assessed at discharge and long term follow-ups were conducted through phone interviews after discharge. Numeric rating scale (NRS) of neck and radiating arm pain, neck disability index (NDI), 5-point patient global impression of change (PGIC), and factors influencing long term satisfaction rates in PGIC were assessed.n = 117) was 2.71  for neck pain, 2.33  for arm pain, and that of NDI 14.6 , and corresponding scores in the non-long term follow-up group (n = 48) were 2.83  for neck pain, 2.48  for arm pain, and that of NDI was 14.86 . Difference in long term NRS of neck pain and arm pain from baseline was 3.15 , and 2.64 , respectively. PGIC was reported to be “satisfactory” or higher in 79.5 % of patients at long term follow-up.Of 165 patients who received inpatient treatment 20.8 ± 11.2 days, 117 completed the long term follow-up up at 625.36 ± 196.7 days post-admission. Difference in NRS between admission and discharge in the long term follow-up group (Though the observational nature of this study limits us from drawing a more decisive conclusion, these results suggest that integrative treatment focused on CAM in cervical IDH inpatients may achieve favorable results in pain and functional improvement.NCT02257723. Registered October 2, 2014.ClinicalTrials.gov Identifier:  Neck pain is a common compliant whose point prevalence is estimated at 10–18 %, with lifetime prevalence reaching 30–50 %. Prevalence of neck pain in populations aged 40 or older is approximately 20 % , and necThe range of available treatments for cervical IDH is vast, spanning conservative treatments to various surgical modalities. Conservative treatments include NSAIDs, oral steroids, steroid injections, patient education, rest, Thomas collars, and physical therapy –14. SurgAccording to Benefits by Frequency of Disease data from the 2013 Korean National Health Insurance Statistical Yearbook , 5585 paSuch CAM treatments as acupuncture, pharmacopuncture, herbal medicine, and manual therapy are well-sought in Korea to the aim of securing a less invasive, non-surgical method of treatment. Jaseng Hospital of Korean medicine, a Korean medicine hospital accredited by the Korean Ministry of Health and Welfare to specialize in spine disorders, treats over 900,000 spinal disease outpatient cases per year. This hospital manages patients with an integrative system utilizing conventional and Korean medicine, where conventional doctors and Korean medicine doctors (KMDs) cooperate for optimal treatment results. Conventional doctors participate in diagnosis using imaging technology such as X-rays and MRIs, and in treatment by caring for a small percentage of patients potentially in need of more intensive care. KMDs supervise and manage the main treatment of all patients, and decide whether the patient requires additional diagnosis and treatment from a conventional doctor. Cervical IDH patients suffering neck pain or radiating pain unable to receive outpatient treatment are thus provided with concentrated non-surgical integrative treatment during admission.Despite the widespread use of inpatient treatment for cervical IDH encompassing a number of treatment modalities, studies on its treatment effect in patients admitted for cervical IDH are scarce. An integrative inpatient treatment approach with focus on CAM may not be widely available to patients, and the objective of this study is to introduce and assess the feasibility and long term effect of this integrative treatment model in inpatients with cervical IDH using a practical study design.This study is a prospective observational study. We observed patients with a main complaint of neck pain or radiating arm pain diagnosed as cervical IDH and admitted from January 2011 to September 2014 at Jaseng Hospital of Korean medicine in Korea which provides integrated conventional and Korean medicine services with CAM as the main modality. The authors conducted a long term follow-up by phone interview during March 2015. Outcome measures covered 5 parts: numeric rating scale (NRS), neck disability index (NDI), patient global impression of change (PGIC), ever-surgery after discharge, and current treatment.This study is a report on part of a registry collecting prospective data on integrated treatment for musculoskeletal disorder patients . The study protocol was approved by the Institutional Review Boards of Jaseng Hospital of Korean medicine. All participants gave written informed consent prior to participation.Admission for treatment of neck pain or radiating arm painCervical IDH confirmed on MRIDiagnosis by KMD that main cause of chief complaint (neck pain or radiating pain) is cervical IDHPatients meeting the following criteria were included.Main complaint other than neck pain or radiating painConcomitant musculoskeletal complaint Cause of neck pain unrelated to cervical IDH .Refusal to participate in the study or nonagreement to collection and disclosure of personal information for study purposesPatients meeting the following criteria were excluded.KMDs assessed the cause of current neck pain or arm pain symptoms with reference to neurological test results  and MRI readings by radiology specialists. Patients who met the proposed inclusion criteria were visited at the inpatient ward on the first day of admission for assessment by a KMD, and followed up using a similar interview and survey process upon discharge. If a patient was admitted multiple times during the study period, only the first admission record was appraised and included.Though the treatment protocol was comprised with most frequented treatments for cervical IDH patients, any and all treatment methods not included in the treatment protocol were allowed and available to all physicians and patients and use of these treatments (type and frequency) were recorded in electronic medical records pragmatically. Conventional treatments such as pain medications and epidural injections  were administered by a conventional rehabilitation specialist through KMD referral. Only non-surgical treatments were allowed during admission.Ostericum koreanum, Eucommia ulmoides, Acanthopanax sessiliflorus, Achyranthes bidentata, Psoralea corylifolia, Saposhnikovia divaricata, Cibotium barometz, Lycium chinense, Boschniakia rossica, Cuscuta chinensis, Glycine max, and Atractylodes japonica). These herbs were carefully selected from herbs frequently prescribed for IDH treatment in Traditional Chinese Medicine and Korean Medicine [Acanthopanax sessiliflorus Seem, Achyranthes japonica Nakai, Saposhnikovia divaricata Schischk, Cibotium barometz J. Smith, Glycine max Merrill, and Eucommia ulmoides Oliver) have been studied in vivo and in vitro as GCSB-5 for their anti-inflammatory [Herbal medicine was taken 3 times/day in pill (2 g) and water-based decoction form (120 ml)  by decocting and freeze drying, then mixing the prepared powder with normal saline and adjusting for acidity and pH. Pharmacopuncture was administered 1 session/day at cervical Hyeopcheok  and Ah-shi points up to 1 cc using disposable injection needles .The pharmacopuncture solution was prepared with ingredients similar to the orally administered herbal medicine  was injected at 4–5 cervical Hyeopcheok  and Ah-shi points at the physician’s discretion. Each point was injected with about 0.2 cc up to a total 0.5–1 cc using disposable injection needles Chuna spinal manipulation , 30, whiAll outcomes were assessed by KMDs who had received prior training and education. Demographic and health behavior characteristics  were collected on the first day of admission using short surveys on current pain levels and neurological exams. Follow-ups were conducted at 2 weeks post-admission or upon discharge and after discharge.NRS  uses an The NDI  is a 10-PGIC  was usedParticipants underwent physical and neurological examination at admission and discharge for objective motor and sensory evaluation of the cervical region. Range of motion (ROM) for neck flexion and extension, distraction, compression, Valsalva, Spurling, Adson’s, and swallowing tests, and upper extremity motor strength and sensory tests and deep tendon reflex tests were performed.All potential adverse events regarding treatment, ranging from skin and local reactions to systemic reactions, and including change or aggravation in pain patterns were carefully observed, recorded and reported during admission. Adverse events associated with bee-venom therapy are known to range from skin reactions to severe immunological responses, and therefore adverse reactions including systemic immunological reactions requiring additional treatment (e.g. antihistaminic agents) were closely monitored. . Blood cell count, liver and renal function tests, and inflammatory activity tests were conducted in all patients at admission, and if there was an abnormal finding requiring follow-up as assessed by KMDs and conventional doctors, relevant markers were rechecked. A total 46 patients were judged to require follow-up at admission by KMDs and conventional doctors and were followed up accordingly during hospital stay, of which 9 patients showed abnormal findings in liver function at admission. Liver function was tracked in these nine patients. Presence of liver injury was also measured to assess possibility of drug-induced liver injury from herbal or conventional medicine intake using a definition of (a) ALT or DB increase of 2× or over the upper limit of normal (ULN) or (b) combined AST, ALP, and TB increase, provided one of them is above 2 × ULN.p < 0.05 was regarded to be statistically significant. Continuous data is presented as mean and standard deviation, and categorical data as frequency and percent (%). The mean difference in NRS of neck pain, NRS of radiating pain, and NDI between admission (baseline), discharge and long term follow-up was analyzed for significance with 95 % confidence intervals (CIs). Satisfaction rate assessed with a 5-point Likert scale at long term follow-up was recategorized into binary values of satisfactory  and dissatisfactory . Multivariable logistic regression analysis was conducted to calculate odds ratios (ORs) and 95 % CIs, and estimate the influence of predictive factors on satisfaction rate. Baseline factors that met p < 0.10 in univariate analysis were included in the final model with age and sex, and factors were selected using stepwise method (p < 0.05).All analyses were conducted using statistical package SAS version 9.3 , and n = 48), 23 patients did not answer the phone, 10 refused to participate in the long term follow-up, and 15 had since changed number or had incoming calls barred . Ten patients were re-admissions and after inclusion of initial admission data if initial admission was during the study period, 165 patients remained. Long term follow-up assessments were conducted in 117 patients. In the non-long term follow-up group  was 2.71  for neck pain, 2.33  for arm pain, and that of NDI, 14.6 . Difference in NRS at long term follow-up for neck pain and arm pain from baseline was 3.15  and 2.64 , respectively. Difference in NRS at discharge in the non-long term follow-up group (n = 48) was 2.83  for neck pain, 2.48 for arm pain , and that of NDI was 14.86 . The between-group difference in effect between admission and discharge in the long term follow-up and non-long term follow-up patients was not significant .NRS of neck pain, NRS of radiating pain, and NDI all decreased significantly at discharge and at long term follow-up compared to baseline (admission) Table . The majThe average period from admission to long term follow-up was 625.36 ± 196.7 days. All 165 patients answered the PGIC at discharge, and of these patients 84.2 % replied that their state was “satisfactory” or higher. A total 117 patients replied to PGIC at long term follow-up, and 79.5 % rated their current state to be “satisfactory” or higher. PGIC was reported to be very satisfactory in 48 patients (41.0 %), satisfactory in 45 (38.5 %), slightly satisfactory in 18 (15.4 %), and dissatisfactory in 6 (5.1 %). Nine patients had undergone surgery (7.6 %), while 21 patients replied that they were currently receiving treatment. Of patients currently under treatment, 10 patients (8.5 %) continued to receive CAM, 12 patients (10.3 %) had selected conventional treatment, and 1 patient was receiving both  at 2 weeks post-admission or discharge out of 234 admitted patients is low, especially considering the short follow-up period. This low compliance may be related to patient attitude toward study participation. As participants did not receive direct compensation for trial participation, they may have lacked incentive to continue participation, and the possibility that patients who refused follow-up assessment were dissatisfied with admission treatment should be considered. Long term assessment was conducted by phone interview in 117 patients (70 %) out of 165 baseline participants partly due to lapse in time, which limited the amount and quality of long term information that could be gathered and led to further patient loss from loss of contact.The largest limitation of our study is probably the inherent quality of a prospective observational study lacking a control. We are unable to draw conclusions on whether the suggested CAM integrative treatment is superior to an active control  or the natural course of disease. Another limitation is the heterogeneity of the patient groups and treatment composition. Participants were cervical IDH patients of varying symptoms, severity and chronicity whose progress are generally known to differ, and interventions included conventional treatments such as epidural injections or pain medications in some cases. Therefore it would be more accurate to construe these results to be the effect of a conventional and Korean medicine integrative treatment system than that solely of CAM integrative treatment. The compliance rate of 74 % , and that VAS scores decreased 36.45, and NDI decreased 12.40 in the conservative treatment group (n = 57) [The 1 year follow-up results comparing conservative treatment and plasma disc decompression (PDD) for contained cervical IDH show that VAS scores decreased 65.73, while NDI decreased 16.7 in the PDD group ((n = 57) . HoweverThe model of integrative treatment used at a Korean medicine hospital may be highly disparate from CAM treatment models used in Western countries. Although CAM treatment is gaining widespread popularity in the West, CAM is usually limited to “complementary” rather than “alternative” medicine, and is generally practiced by conventional practitioners as an adjunctive to conventional treatment after education on acupuncture/naturopathy/etc. or through referral to CAM specialists, of whom some do not hold individual practice rights. On the other hand, Korea adopts a dual medical system where KMDs hold practice rights equal to conventional practitioners, and she does not employ a primarily family practice-based medical system, allowing patients the freedom of primary treatment selection of conventional treatment or Korean medicine treatment. The participants of this study were patients visiting and admitted to a Korean medicine hospital for Korean medicine treatment of cervical IDH, and the integrative treatment model implemented at this Korean medicine hospital does not use CAM as a supplementary measure. Therefore, treatment comprised of CAM treatment such as acupuncture, herbal medicine, Chuna manipulation, and bee-venom pharmacopuncture in most patients, and conventional treatment was administered by conventional doctors through referral in a select few. A total 18.2 % of patients received analgesic medications prescriptions 2.7 times over an average admission period of 20.8 days, which is equivalent to 1–2 days worth’s prescription , and epidural injections were administered to only 4.8 %, which is low considering that these patients required admission. It can be surmised that the main objective of admission in conservative treatment for most cervical IDH patients is alleviation of pain. The fact that many inpatients displayed significant pain and functional recovery in this study holds relevance for patients considering selecting a Korean medicine hospital for conservative treatment over surgery. Also, patients were confirmed to have maintained their improved state at long term follow-up, and only 9 received surgery out of the 117 patients assessed in the long term.Patients were divided into 2 groups by satisfaction rate as evaluated at long term follow-up with PGIC, and multivariable logistic regression analysis was conducted on baseline characteristics to assess predictive factors for satisfaction and dissatisfaction. Older age was associated with higher satisfaction rate, and unilateral radiating pain was shown to be related with higher satisfaction rates than no radiating pain. In addition, patients receiving CAM treatment were associated with higher satisfaction rates compared to those not receiving treatment. This could be partly explained by the fact that more older patients may have higher levels of pain and be in more advanced stages of degeneration, resulting in more favorable and satisfactory treatment outcomes. Similarly, patients with unilateral radiating pain suffer neurological symptoms likely to be more severe than those with no radiating pain. In addition, patients continuing to receive CAM treatment may be more favorably predisposed toward CAM, resulting in higher satisfaction rates.While numerous prospective long term studies have been conducted on injection treatment or surgical procedures, those on CAM treatment and inpatient treatment are few. The results of this study are comparable to the prospective long term results of injection treatment. Few studies have been conducted on admission treatment for patients with a main complaint of cervical IDH, which may be related with the difference in general healthcare systems.In conclusion, although the observational nature of this study limits us from drawing more decisive conclusions lacking a control, 3 weeks’ integrative inpatient treatment mainly comprised of CAM applied to actual clinical settings may result in satisfactory results and pain and functional improvement maintained in the long term in neck pain or radiating arm pain patients diagnosed with cervical IDH.


To describe the functional outcomes in patients aged ≤18 years with anterior knee pain treated with medial plica excision with or without lateral release.We identified 135 patients including 30 bilateral cases (165 knees) with a mean ± SD age of 15.1 ± 2.0 years. Patient and surgical information was recorded and a follow-up athletic questionnaire and an International Knee Documentation Committee (IKDC) Subjective Knee Evaluation form were sent out. Statistical analysis evaluated predictors of residual pain, reoperation, return to sports, IKDC score and satisfaction with surgery.P = 0.06. Mean IKDC score (107 knees) was 76.9 ± 17.8 (range 31–100). Most patients  were satisfied with surgery and were able to return to sports .At a final mean follow-up of 4.4 years (range 2–7.5), 36 % of patients were pain free, 46 % had mild residual pain and 18 % had pain not improved from surgery. Reoperation was more likely following isolated plica excision  versus plica excision with lateral release , although not statistically significant, While most patients were satisfied and able to return to sports following plica excision with or without lateral release, residual symptoms were common. Anterior knee pain is a common complaint in adolescents, with multiple potential causes often included under the diagnosis of ‘patellofemoral syndrome’ –3. The mThe plica may be palpable and tender locally with compression over the medial femoral condyle. Plain radiographs and magnetic resonance imaging (MRI) are often non-diagnostic; therefore, the diagnosis is usually clinical . Prior rLateral patellar tracking and a tight lateral retinaculum have also been implicated in anterior knee pain , 18–20. The aim of this study is to describe the clinical and functional outcomes in a large series of adolescents with anterior knee pain treated with plica resection with or without lateral release. Secondary aims include elucidating predictors for residual pain at final follow-up, need for reoperation and satisfaction with surgery. Results in knees treated with isolated excision of the medial synovial plica were compared to those treated with plica excision plus lateral release to determine if the addition of lateral release improved postoperative outcomes. We hypothesize that plica resection with or without lateral release will result in good clinical and functional outcomes and a high rate of return to sports. We also hypothesize that the addition of lateral retinacular release to plica excision will lead to higher functional scores with a lower reoperation rate and less residual pain.After institutional review board approval, computerized medical records were searched to identify all patients aged ≤18 years who underwent arthroscopic medial synovial plica excision with or without lateral retinacular release for the treatment of anterior knee pain at our institution from 2005−2010. Patients who had prior knee surgery or who had undergone concurrent meniscal repair or patellar stabilization were excluded. The search identified 222 patients of whom 67 had <2 year follow-up from surgery and were excluded. Thirteen others had prior knee surgery and were excluded. An additional seven patients refused study participation. This resulted in a final study population of 135 patients including 30 bilateral cases . The mean ± SD age of the cohort was 15.1 ± 2.0 years  and the mean follow-up was 4.4 years (range 2–7.5). All procedures were performed by one of five fellowship-trained sports medicine pediatric orthopedic surgeons with the majority (161/165) performed by four of the surgeons.For each patient, we reviewed clinical records and imaging to record patient data, surgical procedure, clinical results and complications. In most cases, the primary surgeon evaluated the patient prior to surgery and recorded a detailed history and physical examination, which was available for our review. Through retrospective chart review, we recorded the primary surgeon’s preoperative diagnosis based on clinic notes prior to surgery as (1) isolated medial plica syndrome, (2) plica syndrome with lateral patellar friction syndrome, (3) isolated lateral patellar friction syndrome, or (4) other. Patients were classified as having plica syndrome if they had medial peripatellar pain worsened by palpation of a medial plica  . PatientPreoperative MRI was reviewed in 96 knees and used to assess the distal femoral physis and anatomy of the patellofemoral joint. Patellar height  –27, tibiConservative measures were prescribed in all cases including physical therapy, patellar bracing, activity modification and anti-inflammatory medications. In some cases a diagnostic/therapeutic plica injection was performed. Similar to other authors , the indSurgical complications, reoperations, residual symptoms  and ability to return to sports were determined through chart review for all patients. At the time of study initiation, all patients were contacted by mail or phone and asked to complete a follow-up athletic questionnaire and an International Knee Documentation Committee (IKDC) Subjective Knee Evaluation form. The follow-up athletic questionnaire focused on sports participation before and after surgery, time to return to sports and satisfaction with surgery.Standard knee arthroscopy under tourniquet was performed in all patients. Resection of the medial synovial plica was completed using a motorized shaver through the anteromedial portal Fig. . The pliStatistical analysis was conducted to evaluate potential predictors of residual pain at final follow-up (mild or same vs none), need for reoperation, ability to return to sports, IKDC score, satisfaction with surgery and self-reported recurrence of symptoms. Risk factors assessed included age, gender, BMI (at time of surgery), duration of patellar pain , patella alta , abnormal TT−TG distance (>14 mm), abnormal LPFA (<8°), physis status, primary surgeon’s preoperative diagnosis, procedure performed, and presence of chondral changes.For the 30 bilateral patients, reoperation rate, time to reoperation, presence of residual knee pain, IKDC score, satisfaction with surgery, and self-reported recurrence of symptoms were analyzed separately for each knee. Since return to sports is a global patient outcome, for patients with bilateral surgeries within one year (26 patients) only one knee was considered in return to sports analysis, with time to return measured from the second surgery if they were on separate days. In four patients, with lag times between surgeries of 1, 1, 1, and 4 years, respectively, each knee was considered separately. For purposes of evaluating associations between knee characteristics and return to sports, we let the ‘worse’ knee determine the characteristic for patients with bilateral surgeries performed on the same day (9 patients). At the start of the study, bilateral patients were initially asked to complete the IKDC score only for their more symptomatic knee. If the questionnaire responses for that knee were uniformly perfect  we conservatively assumed the same IKDC score for the other knee. As the study progressed, bilateral patients were asked to complete separate questionnaires and IKDC scores for each knee. IKDC scores were re-scaled to a 0–100 scale. For one subject, who left a missing value on one item, the re-scaled score was based on all completed items as described by Anderson et al. .t-test and analysis of variance. Comparisons with respect to categorical variables were made with Fisher’s exact test. The statistical assumption of independent observations was partially violated due to the subgroup of patients with bilateral surgeries contributing data from two knees each. However, in a sensitivity analysis using generalized estimating equations to account for clustered data, we confirmed that results and conclusions were substantively unchanged. P-values are two-sided and considered statistically significant when P < 0.05.Time to return to sports and time to reoperation were illustrated using the Kaplan–Meier method. Subgroups were compared with respect to the IKDC score using the Major characteristics of the study population are summarized in Table Table P = 0.01. Since lateral release was performed in almost all knees (114/117) that had a preoperative diagnosis of lateral patellar friction syndrome (±plica), statistically meaningful conclusions regarding the role of lateral release in residual knee pain could not be drawn from these other preoperative diagnoses. Residual knee pain at final follow-up was less common in knees with a preoperative duration of patellar pain <12 months  versus 13–24 months  and surprisingly least common for patients with preoperative symptoms >24 months  P = 0.05. There were no other significant predictors (including preoperative imaging characteristics) for residual knee pain.Residual knee pain was retrospectively assessed at most recent follow-up for all patients. In the entire cohort of 165 knees, 59 (36 %) were pain free, 76 (46 %) had residual (improved) pain, and 30 (18 %) had continued residual pain without improvement from surgery. The effect of lateral retinacular release on residual knee pain was analyzed separately for each preoperative diagnosis. When the primary surgeon’s preoperative diagnosis was isolated plica syndrome, residual knee pain was statistically more likely following isolated plica excision  versus plica excision with lateral release  After surgery, 104/120 (87 %) patients were able to return to sports. In 45 knees, return to sport data was unavailable or omitted from analysis due to bilateral surgery see ‘’. There P = 0.06). At time of reoperation, the plica was noted to have reformed in 11/15 knees. Procedures performed at reoperation included plica excision with lateral release (6 cases), isolated plica excision (4 cases), isolated lateral release (4 cases) and lysis of adhesions (1). Of these 15 patients, 11 reported residual but improved pain following reoperation, 2 patients had similar persistent pain and 2 were pain free at last clinic visit.There were 15 reoperations for persistent anterior knee pain (9 %). Time to reoperation is depicted in Fig. P = 0.06). A total of 87 patients completed the follow-up athletic questionnaire for 99 knees  knees. The mean IKDC score was 76.9 ± 17.8 range 31–100), median 80.5 (interquartile range 64.4–93.1). Although assessed retrospectively, the mean score for the IKDC function question which assesses overall knee function on a 1–10 scale (10 = no limitations) was 5.2 before surgery compared to 8.2 at the time of the survey. There were no significant predictors of IKDC scores, including lateral retinacular release. Males (7 knees) had higher mean IKDC scores (89.2 ± 13.8) than females (76.1 ± 17.8) but this did not reach statistical significance  and outcomes . There were no significant differences between the groups.This study reports on a large group of adolescents with anterior knee pain and a medial patellar plica treated with plica excision with or without lateral release. At mean follow-up of 4.4 years, most patients were satisfied, able to return to sports and experienced improvement in preoperative symptoms although residual symptoms were often still present. In total, 90 % of patients in our study were female which likely relates to the increased incidence of anterior knee pain/lateral patellar friction syndrome/lateral patellar maltracking in the adolescent female population. While prior reports on plica syndrome have not demonstrated such a high rate of females, this study is the only one to focus on the adolescent population. Our data support the notion that in adolescents, plica syndrome often represents a component of the much larger problem of abnormal patellofemoral biomechanics. In concordance with this is the preponderance of females reported in other studies involving lateral retinacular release in adolescents .While this report focuses on operative management, we would like to emphasize that the majority of adolescents with anterior knee pain in our clinic are treated conservatively and recover without surgical intervention. The authors continue to believe that conservative management options should be exhausted in all patients. Prior authors have reported that 60 % of patients with plica syndrome attain resolution of symptoms after 1 year of conservative therapy, whereas 40 % have no benefit and eventually undergo surgery . Our repA unique aspect of our study is that we chose to analyze the primary surgeon’s preoperative diagnosis as a potential predictor for surgical outcome. While this introduces potential bias (as the preoperative diagnosis was gleaned from retrospective chart review) the authors used rigid criteria as defined above to classify patients. This was done to determine if patients with a preoperative diagnosis of isolated plica syndrome had a better clinical outcome versus other diagnoses including lateral patellar friction syndrome. No such relationship was seen which may reflect study limitations or may implicate an impinging medial synovial plica in some cases of lateral patellar friction syndrome. While the MRI data in our study are unique, no relationship was shown between the studied patellofemoral anatomic factors and surgical outcomes.Our study also involves a significantly younger age group than most prior reports. It has been hypothesized that a medial plica may become prominent during the adolescent growth spurt as the extensor mechanism tightens . Prior sDorchak et al.  reportedWe feel that a symptomatic medial plica is often a sign of an underlying patellar maltracking or tilt disorder. A tight lateral retinaculum may worsen medial plica contact by providing a lateral restraint/pull to the plica throughout knee range of motion. Other authors have associated pathologic medial plica formation with lateral patellofemoral tilt or tracking , 37, 38.P = 0.06). While we continue to support lateral release if a tight lateral retinaculum is noted intraoperatively, its effect on surgical outcome and the subgroups that may benefit most remain unclear.In our population we could not identify a specific subgroup  that would clearly benefit from lateral release. For patients with isolated plica syndrome, significantly less residual pain was seen in the lateral release group but this was limited by the small number of patients (6) in that subgroup. The strongest evidence in support of lateral release may be the overall lower reoperation rate (17 vs 6 %, Study limitations include its retrospective nature, lack of long-term follow-up, lack of preoperative functional scores, variable preoperative diagnoses and limited postoperative subjective functional data. There is also potential for selection bias from surgeon preference for performing a lateral retinacular release and the potential for variability in the amount of plica resected amongst individual surgeons. Our subgroup analyses were limited in many cases by small numbers, which likely hindered identifying subtler clinical differences. In addition, the follow-up athletic questionnaire employed, while informative, has not been previously validated and was only completed in 99 cases, which limits the return to sport analysis.In conclusion, for adolescents with anterior knee pain refractory to conservative management, plica excision with or without lateral release resulted in a high rate of surgical satisfaction and ability to return to sports. However, residual symptoms were common and only 30–40 % of patients were pain free. The addition of lateral release to plica resection did not result in a clinical benefit based on IKDC scoring but may diminish the need for reoperation in the adolescent population.


Background and aims. Postoperative pain control is extremely important for both patients and surgeons; in this context, long-acting local anesthesia can play an important role after open reduction of maxillofacial fractures. The purpose of this study was to evaluate the effect of bilateral mental nerve block with bupivacaine on postoperative pain control in mandibular symphyseal fractures.Materials and methods. Fifty patients with pure mandibular symphyseal fractures were studied in two control and study groups. In contrast to the control group, the study group received bilateral mental nerve block with bupivacaine postoperatively. Patients were examined in relation to pain severity and opioid analgesic drug need sequences.Results. The study group needed significantly less opioid than the control group . The control and study groups were different in first opioid administration time. The control and study groups received first opioid dose in 0-2 and 2-4 hours, respectively.Conclusion. Bilateral mental nerve blocks with bupivacaine can reduce opioid analgesic need and it has a positive effect on postoperative pain control in mandibular symphyseal fractures. Ventilatory depression and vomiting are among the latter category, especially in early postoperative hours. Various methods have been proposed to minimize these side effects. Nerve block with long-acting local anesthesia is a proposed technique in this regard. These solutions have been used in many procedures like limb fractures with open reduction, graft donor site surgeries, laparoscopy and arthroscopy. Femoral nerve block was used for extracapsular femoral neck fracture by Haddad and Williams in 1995.2 Dashow, Coulthard, Hoard, Sbitany, Haenel and Furst studied the effect of bupivacaine as a local anesthetic for pain control and morbidity reduction of iliac bone harvesting sites, rib fractures and temporomandibular joint arthroscopy.6 In maxillofacial field, bupivacaine has been used as a safe local anesthetic solution for pain control after cleft lip operation or third molar surgery, alone or in combination with low-power laser and diclofeanc.13 Bupivacaine is a well-known long-acting local anesthesia solution.14 The aim of the current study was to evaluate the efficacy of bi-lateral mental nerve block with bupivacaine in post-operative pain control and reduction of total analgesic drug need in patients referring to a trauma center with mandibular sysmphyseal fractures.Postoperative pain control is one of the most important phases of most surgical procedures. Due to the surgical trauma and subsequent cascade release of pain mediators, the receptors of pain are stimulated, resulting in various degrees of pain in the postoperative period. Therefore, both the surgeon and anesthesiologist are involved and interested in pain control during and after the operation. Various methods of analgesic drug administration have been proposed by clinicians to help relieve patients’ pain experience immediately after surgery. The goal of every postoperative pain management technique is to reduce or eliminate pain and discomfort with minimum side effects. Opioid drug administration is a common technique to reduce pain from surgical trauma. However, the use of large doses of opioid drugs during and after surgery can be associated with an increased incidence of ventilatory depression, sedation, nausea, vomiting, pruritus, difficult voiding and ileus.2O, %5 O2, isoflurane 1-1.5% for maintenance and 1.5 mg atropine and 2,5 mg neostigmine for reversing of the anesthesia.A double-blind case-control prospective study was performed on the patients with pure parasymphyseal fractures, referred to the Oral and Maxillofacial Department Clinic for treatment of their fractures. Patients were examined clinically by clinical staff. Their pure parasymphyseal fractures were confirmed by proper radiographic examinations. Before initiation of the study, its protocol was approved by institutional ethics committee. All the patients and their relatives were informed about the details of the study and written informed consent was obtained by the researchers. Sample size was estimated by using data of a previous pilot study. A total of 50 patients were randomly allocated to two groups  using a random number generator. Inclusion criteria consisted of patients having pure symphyseal fracture, who did not have any systemic diseases and did not use any medication that would alter pain perception. All the patients with any history of allergy to local anesthetics and those under 18 were excluded. Anesthesia protocol was planned by an anesthesiologist with the same drugs for all the patients: 2 mg/kg propofol, 2 μg/kg fentanile, 0.05 mg/kg midazolam, 0.4 mg/kg for induction of anesthesia, %50 NBoth the patients and surgeon were blinded to the use of local anesthesia since the labels of anesthetic solution were pulled off and the cartridges were coded by one of the nursing staff who was not directly involved in data collection. The same surgeon performed all the surgeries using an intraoral approach according to the Champys’ miniplate fixation rules. Mental nerve is usually located between the apices of the first and second premolars. The mucobuccal fold and mandibular premolars are good landmarks for this block. In the study group at the end of surgery, immediately after completion of surgical wound closure, two mL of 0.5% bupivacaine hydrochloride with 1:200000 epinephrine were injected for each side  using a 25-gauge short needle toward the apices of mandibular premolars with bevel orientation toward the bone. The depth of penetration was 5 to 6 millimeter without entering into the mental foramen. Then the syringe was aspirated and if negative, anesthetic solution was injected over 20 second .The control group did not receive any nerve block injection. Pain severity was assessed by using visual analog scale from 0 to 10. Pain assessment was performed from the time of extubation and in the recovery room up to 24 hours by nursing staff that were blinded to the intervention. If the pain score was over 6, the patients (regardless of the study or control group) received 25 mg of pethidine intramuscularly  for their postoperative pain as a backup analgesic drug according to regular nursing observation and hospital protocol. All the patients were examined in relation to pain severity and opioid analgesic need sequences. Mann-Whitney U test was used to compare the opioid analgesic drug need and first opioid dose time. Data were analyzed with SPSS 16 and statistical significance was set at P<0.05.Forty male and 10 female subjects, with an age range of 18-40 years, met all the criteria for this research. The patients’ average body weight was 64 kg ranging from 53 kg to 77 kg. No significant differences were found between age and gender (P>0.05) in both groups. There was a significant total mean difference between the intervention and control groups in the frequency of opioid drug need the study group needed less opioid than the control group  . Seven p15 Hyrkas et al16 studied the use of bupivacaine and lidocaine in combination with sustained-released preparation of diclofenac in postoperative pain control of third molar surgery. They reported high efficiency of combined bupivacaine versus lidocaine. The same results were achieved by Singh and Bhardwaj17 using continuous mandibular nerve block with bupivacaine for postoperative pain relief of mandibular fracture surgeries. The present study confirms previous investigations. Generally, opioid drugs are a common way of pain control in nearly all the surgeries. The important things that we should take into account are the side effects of drugs. In some instances side effects are the unavoidable part of drugs. Perrott et al18 found postoperative nausea and vomiting to be the most common postoperative complications after oral and maxillofacial surgeries. Silva et al19 reported a prevalence rate of 40% for these complications after maxillofacial surgeries. Bilateral mental nerve block can reduce the need for opioid analgesic drugs, eliminating the drugs’ side effects. This method can also be a useful technique for combined maxillofacial and brain traumatic patients. Ventilatory depression and sedation, on the other hand, can also be fatal for these patients. Significant time difference for the first needed dose of opioid in the study group provides a good opportunity for surgeons to evaluate the level of patients’ consciousness. Vomiting and aspiration risk can be doubled in emergency situation and urgent maxillofacial surgeries. Bilateral symphyseal fracture in unconscious patients is an emergency situation because posterior displacement of fractured symphysis by genioglossus and geniohyoid muscles can block the airway concomitant with tongue position. Use of bilateral mental nerve block at the end of the surgery delays the first opioid drugs need and reduces the total dose of analgesic drugs; therefore, medical and nursing staff have enough time to re-evaluate the level of patients’ medical and consciousness conditions without any sedative drug interaction. Addiction to opioid analgesics is yet under clinical and psychosocial investigation. Risk of addiction in psychologically susceptible patients is another side effect of opioid drugs. Reduction of total post-operative opioid doses and patients’ need may have an effective influence on such issues.Due to the severity of pain and other complications, early postoperative hours are very important for both the patients and surgeons. Opioid administration is a common way to overcome the pain sequelae in nearly all the surgeries including those in the maxillofacial region. However, the vomiting side effect associated with the opioids may be a especially life-threatening complication in maxillofacial surgeries since these patients often undergo intermaxillary fixation which inhibits the proper drainage of the vomit from the oral route, adding an increased risk of pulmonary aspiration. Therefore, reduction of the opiod dose needed after surgery may be a prudent clinical objective after maxillofacial surgeries. Long-acting anesthesia on the other hand may provide a pain relief gate for the patient, reducing the need for opioids. These anesthetics have been examined in various surgical procedures. Bouloux and Punnia-Moorthy in a randomized, double-blind, crossover study compared the clinical use of bupivacaine and lidocaine in third molar surgery in two separate sessions. Bupivacaine was used for the third molar surgery on one side, whereas lidocaine was used for the other side. Pain experience, analgesic consumption, cardiovascular response, blood concentration and systemic toxicity were evaluated. Bupivacaine significantly reduced postoperative experience only for eight hours. The results of their study did not show a difference in a variety of parameters, other than postoperative pain experience.For reasons mentioned above, bilateral mental nerve block with bupivacaine can be an effective and safe method for reducing opioid  drugs need and controlling of postoperative pain and discomfort in mandibular symphyseal fractures.


Validated clinician outcome scores are considered less associated with psychosocial factors than patient-reported outcome measurements (PROMs). This belief may lead to misconceptions if both instruments are related to similar factors.We asked: In patients with chronic shoulder pain, what biopsychosocial factors are associated (1) with PROMs, and (2) with clinician-rated outcome measurements?All new patients between the ages of 18 and 65 with chronic shoulder pain from a unilateral shoulder injury admitted to a Swiss rehabilitation teaching hospital between May 2012 and January 2015 were screened for potential contributing biopsychosocial factors. During the study period, 314 patients were screened, and after applying prespecified criteria, 158 patients were evaluated. The median symptom duration was 9 months , and 72% of the patients (114 patients) had rotator cuff tears, most of which were work injuries  and were followed for a mean of 31.6 days . Exclusion criteria were concomitant injuries in another location, major or minor upper limb neuropathy, and inability to understand the validated available versions of PROMs. The PROMs were the DASH, the Brief Pain Inventory, and the Patient Global Impression of Change, before and after treatment . The Constant-Murley score was used as a clinician-rated outcome measurement. Statistical models were used to estimate associations between biopsychosocial factors and outcomes.Greater disability on the DASH was associated with psychological factors  and social factors . Greater pain on the Brief Pain Inventory was associated with psychological factors . Poorer impression of change was associated with psychological factors  and social factors . Worse clinician-rated outcome was associated only with psychological factors , Pain Catastrophizing Scale, Tampa Scale of Kinesiophobia combined coefficient, −0.35; 95% CI, −0.58 to −0.12; p = 0.003).Depressive symptoms and catastrophizing appear to be key factors influencing PROMs and clinician-rated outcomes. This study suggests revisiting the Constant-Murley score.Level III, prognostic study. There are various factors that can affect the results of treatment after shoulder injuries and there is no general consensus regarding which are the most decisive , 16. StuTo date, the majority of research on this topic has focused on specific aspects  and predominantly used subjective outcomes. There is a lack of studies analyzing potential biopsychosocial factors and their effect on outcome scores using clinician-rated measurements and subjective outcome scores (patient-reported). Comparing instruments that measure physical impairments such as strength and mobility (recorded by clinicians) with others measuring only subjective perceptions of pain and disability appears to be important. For instance, surgeons or physiotherapists who feel underskilled to deal with patients’ subjective perceptions might be tempted to prioritize measurements rated by experienced clinicians rather than those related to patients’ perceptions. Nevertheless, this belief may lead to misconceptions and give incorrect information if both instruments are related to similar nonbiological factors. Recently, Roh et al.  found thTherefore, we asked the following questions: (1) In patients with chronic shoulder pain, what biopsychosocial factors are associated with PROMs? (2) What biopsychosocial factors are associated with clinician-rated outcome measurements?We conducted a single-center retrospective study with a total of 158 patients. This study was done at the Clinique Romande de Réadaptation in the French-speaking part of Switzerland. Patients, mostly blue collar workers with shoulder injuries, were included between May 2012 and January 2015. Patients are referred from all of the French-speaking counties of Switzerland, which includes urban and industrial city centers or more rural regions . The patThe electronic patients’ files allowed all patients with shoulder injuries to be identified. Shoulder injuries were classified in the following categories: rotator cuff/bursa injuries and other shoulder injuries . Inclusion criteria were unilateral shoulder injury and being between 18 and 65 years old. Exclusion criteria were bilateral injuries, concomitant injuries in another location , presence of an upper limb neuropathy (major and minor), or any missing data. Patients unable to read and understand the available validated versions of the PROMs also were excluded (see below). The protocol was approved by the local medical ethics committee (CCVEM 041/07). The study was performed in accordance with the ethical standards in the 1964 Declaration of Helsinki.Potential contributory factors were collected from routinely administered scales and medical records for all patients, and these were divided into biological, psychological, and social factors. Biological factors include 1) diagnosis category (rotator cuff/bursa injuries versus others); (2) Abbreviated Injury Scale (AIS) score (minor injury versus others)  diagnosi, which aPsychological factors consisted of (1) the presence or absence of psychiatric diagnosis by a senior psychiatrist according to the ICD-10 classification ; (2) Tampa Scale for Kinesiophobia  ; (3) PaiSocial factors included (1) educational level (≤ 9 years compulsory schooling versus > 9 years); (2) qualified work (yes versus no); (3) ability to speak the native language of the clinic ; (4) and social subscale  of the INTERMED tool .Questionnaires regarding medical comorbidities are compulsory in all Swiss rehabilitation hospitals; the INTERMED has been used since 2003, and the other questionnaires since 2012 in our hospital. The PROMs were validated, translated versions .Other potential confounding factors accounted for included age, sex, and pain severity at admission.Outcomes (before and after treatment) were categorized into two categories: patient-reported and clinician-rated. The PROMs studied included measures of disability (restriction in activities and participation), pain, and impression of change, as measured by the DASH, the Brief Pain Inventory questionnaire, and the Patient Global Impression of Change measure, respectively.The DASH score  is a comClinician-rated outcome was measured using the Constant-Murley score , which iTo minimize the measurement bias, all records were collected electronically, without transcription from paper to the data files. All validated questionnaires were given in French and in foreign languages. Despite availability of other versions, we could not cover the entire panel of languages spoken in our clinic. Switzerland has a large number of immigrant workers who speak numerous languages. This partially explains why many eligible patients were not included (selection bias). The INTERMED, a validated semistructured interview , 39, wasDuring the study period, 314 patients were eligible. Unmet inclusion criteria, missing data, and inability to read or understand few questionnaires led to disqualification of 156 subjects , with more than 1/2 being of foreign background, and 2/3 lacking a professional qualification. The majority were industry and construction workers (with mostly rotator cuff ruptures) .Because some of the continuous variables were positively correlated, we built new variables as their geometric mean. Binary variables that were associated between each other also were grouped as new binary variables. This reduces the risk of collinearity in multivariable models.All variables with a probability less than 0.10 were kept in the multivariable models. We then applied a backward elimination to select the final models as those which minimized the Akaike Information Criterion. All of these multivariable models contained the same adjusting variables as previously. A sample size consisting of 158 patients allows us to start the model selection procedure with up to 10 candidate factors (more than 15 observations per parameter) .® 13.1 . The significance level was set as a probability less than 0.05.All analyses were performed with StataPoor patient-reported outcomes are associated with psychological and social factors, but not biological factors, with the exception of the Brief Pain Inventory Table . GreaterSimilarly, a worse Constant-Murley score was associated with psychological factors , but not biological factors Table . Social The factors related to clinical changes and disability in patients with shoulder pain are variable and go well beyond biological and objective data , 32, 35.Our study had numerous limitations. First, the unusual setting may induce a limitation in generalization of the results . However, our focus was on middle-aged patients with chronic shoulder pain , who may have difficulty returning to heavy work. The type of rehabilitation hospital, such as our clinic, is relatively common throughout Europe. The selection bias with an exclusion rate of 49% of eligible patients is partly attributable to the retrospective design of the study. Another reason that explains the bias was the lack of validated questionnaires for several nonnative speakers. In additional, our electronic data medical records previously were not calibrated to signal missing or aberrant values and we decided to include only patients with complete data. However, only minor differences in the investigated variables were found between included and excluded patients .Higher level of depression symptoms, catastrophizing thoughts, and fear of movement were related to poorer outcome measured with the Constant-Murley score. These psychological factors are all components of the Fear-Avoidance Model, one of the most popular theoretical frameworks in chronic pain . So far,The results of our study suggest that psychological factors are associated with clinician and patient shoulder outcome instruments, and consequently, should be screened appropriately (particularly depression and catastrophizing). How the patient presents therefore can influence the clinician’s judgement . Careful


Manual therapy as spinal manipulation, spinal mobilization, stretching and massage are common treatment methods for neck and back pain. The objective was to compare the treatment effect on pain intensity, pain related disability and perceived recovery from a) naprapathic manual therapy  to b) naprapathic manual therapy without spinal manipulation and to c) naprapathic manual therapy without stretching for male and female patients seeking care for back and/or neck pain.n = 1057) were randomized to one of three treatment arms a) manual therapy , b) manual therapy excluding spinal manipulation and c) manual therapy excluding stretching. The primary outcomes were minimal clinically important improvement in pain intensity and pain related disability. Treatments were provided by naprapath students in the seventh semester of eight total semesters. Generalized estimating equations and logistic regression were used to examine the association between the treatments and the outcomes.Participants were recruited among patients, ages 18–65, seeking care at the educational clinic of Naprapathögskolan - the Scandinavian College of Naprapathic Manual Medicine in Stockholm. The patients (p = 0.41) and pain related disability (p = 0.85) and perceived recovery (p = 0.98). Neither were there disparities in effect when male and female patients were analyzed separately.At 12 weeks follow-up, 64 % had a minimal clinically important improvement in pain intensity and 42 % in pain related disability. The corresponding chances to be improved at the 52 weeks follow-up were 58 % and 40 % respectively. No systematic differences in effect when excluding spinal manipulation and stretching respectively from the treatment were found over 1 year follow-up, concerning minimal clinically important improvement in pain intensity (The effect of manual therapy for male and female patients seeking care for neck and/or back pain at an educational clinic is similar regardless if spinal manipulation or if stretching is excluded from the treatment option.ISRCTN92249294Current Controlled Trials  Neck and back pain is common and costly in the general population, and represents an enormous financial burden. The costs stem from loss of work and medical expenses, as well as other direct or indirect expenses , 2. LifeRubinstein et al. included in a systematic review a few studies showing that spinal manipulation was more effective for low back pain than mobilization in the short term but not in the long term. Other studies that did not find any difference in effect between the two techniques, and no conclusion was drawn regarding this . StretchAccording to recent studies naprapathic manual therapy (NMT) is an effective and cost effective treatment alternative for musculoskeletal pain both in the short and the long term –18. NaprNMT is a young area of research and further studies are needed to develop the discipline and to ascertain quality assurance. Aspects of this are the risk of adverse events and if treatment effects and risks differ between different combinations of NMT . We have performed a three-arm randomized controlled trial (RCT) called the Stockholm MINT-trial , where these questions are addressed, in order to ease the consideration between risks and benefits in the choice of treatment strategies for these patients. One study is published based on the first 767 included patients seeking care for non-specific back and/or neck pain in which we found no systematic differences in the risk of adverse events between the treatment arms . Based oThis study is a three-arm randomized controlled trial (RCT), and the trial was registered in Current Controlled Trials (ISRCTN92249294).The treatments were given at the educational clinic of the Naprapathögskolan - Scandinavian College of Naprapathic Manual Medicine, Stockholm, Sweden. The students, who provided the treatments were in their seventh out of eight total semesters, with experience regularly (twice a week) treating patients over a period of five semesters. These treatments include massage and stretching techniques during five semesters, spinal mobilization techniques during three semesters and spinal manipulation techniques during two semesters under supervision of experienced registered naprapaths. The supervision included regular controls of the compliance of the study protocol. The primary investigator and the research team regularly had meetings and education with the students as well as with the supervising naprapaths/teachers. Senior students that participated in the current trial had passed all practical clinical examinations at this level of the education which includes all the manual techniques used.th thoracic vertebra, with or without pain in upper extremities and chest) and/or back pain  and who had not visited the educational clinic during the previous month.The participants eligible for this study were patients, 18–65 years old, seeking care for neck pain  Not mastering the Swedish language, 2) having scored <2 on a numerical rating scale (0–10) in two questions regarding pain intensity (pain at the present time and the worst pain during the past 4 weeks) in neck and/or back, 3) pregnancy, 4) current or previous cancer, 5) having received treatments for the current complaint by a chiropractor, naprapath, osteopath or physiotherapist during the past month, 6) duration of the current complaint less than 1 week, 7) patient demand/deny spinal manipulation/stretching, 8) contraindication for spinal manipulation according to the Swedish Board of Social Welfare , 9) indiPotential study participants were marked in a ledger at the clinic by a trained receptionist according to inclusion criteria; age, neck and/or back pain and no visit at the educational clinic during the past month. The inclusion process was handled by the supervised and trained student therapists: information about the study to the patients, obtaining of informed consent, the baseline data collection, the decision about inclusion, and the randomization allocation. The therapists as well as the supervising experienced registered naprapaths were thoroughly trained in different aspects of the study protocol at a number of meetings before the start of the study. Uncertainties and questions were discussed in regular weekly meetings during the inclusion period.A trained research assistant made the randomization in advance and prepared sequentially numbered opaque and sealed envelopes with cards numbered 1, 2 or 3, by drawing these cards from a box. Stratified randomization was used, based on the location of pain: 1) neck and upper back 2) lower back and 3) neck and lower back . For each stratum, randomization in blocks of 99 were performed.Potential study participants were informed about the study at the first visit. Informed consent was obtained and patients completed the baseline questionnaire suited for the area of pain before the physical examinations and diagnostic assessment by the therapists. The patient and the therapist were unaware of the group assignment until after all baseline data were collected. Treatment allocation was performed by the therapist after the physical examination and the completion of the baseline questionnaire. The therapists were told not to share the result of the randomization to the patient if possible, however this cannot be considered as blinding the patient to the treatment. Each treatment session was scheduled for 45 min.Naprapathic Manual Therapy (NMT): The therapist was allowed to use all techniques within NMT i.e. spinal manipulation, spinal mobilization, muscle stretching, massage and other soft tissue techniques.NMT excluding spinal manipulation: The therapist was allowed to use all available techniques within NMT except spinal manipulation.NMT excluding muscle stretching: The therapist was allowed to use all techniques within NMT except muscle stretching.The interventions in all three arms were conformed to the patients’ condition, however standardized to the greatest extent possible concerning, for example, the length of treatment sessions and how to perform them in different situations, by several education meetings held in advance. The therapists were told to use all manual therapy techniques that were included in the treatment arm according to the randomization protocol, but no other treatment modalities.To ensure that the treatments were performed according to the randomization protocol, a random sample of 6 % of the medical records were control post treatment.The baseline questionnaire was based on questionnaires used in previous studies , 21 and Information of outcomes was collected by self-administrated postal or web-based questionnaires at follow-up, after seven, 12, 26 and 52 weeks. If a patient did not answer or if the questionnaire was not complete, a trained research assistant contacted the patient by phone, mail or letter to remind them, at a maximum of three occasions.Primary outcomes were pain intensity and pain related disability. Patients graded their pain in three pain questions  measured with a numeric rating scale, 0–10  with the modified CPQ . Three qA minimal clinically important improvement (MCI) in pain was defined as a decrease by at least 2 points in pain intensity score at follow-up compared to baseline and a MCI in disability was defined as a decrease by at least 1 point in pain related disability score at follow-up compared to baseline , 25–27.Which of the following statements is most consistent with how you feel your problems in the neck/lower back has changed since you joined this study?”. The answer alternatives were; 1) Am completely free from pain and have no other complaints originating from neck/ back, 2) Am considerably improved, 3) Am slightly improved, 4) No change, 5) Am slightly worse and 6) Am much worse. For the comparison between groups the answers were dichotomized into recovered /not recovered . Further a question about additional care administered for the neck/back pain the preceding 3 months was included in the follow-up questionnaire.Secondary outcomes were perceived recovery was measured by the question, “Power analyses based on the primary outcomes  in pain and disability) were performed before the Stockholm MINT trial started, to determine the sample size required. A total of 350 patients per treatment arm, in total 1 050 patients, indicated a power of >80 % to detect a relative risk (RR) of 1.2 to 1.3 for a clinically important improvement in pain and disability in sub group analyses  of 150 patients, regarding the primary outcomes.Analysis was done with an intention to treat approach. To analyze if there were any differences between the treatment arms in MCI in pain and disability and perceived recovery, and to test for confounding, logistic regressions using generalized estimating equations (GEE) were conducted, in all participants and in gender stratified analyses. For further testing if there were any differences in mean pain/disability score, linear regressions using GEE was used taking into account the covariance between repeated measurements of pain and disability, in all participants and in gender stratified analyses , 29. TheThe study population for the analyses of mean scores of pain intensity and mean score pain related disability, and for the analyses of perceived recovery, was 1057 patients seeking care for non-specific back and/or neck pain . At 12 weeks follow-up 61 % had a MCI in pain intensity, and 41 % in pain related disability. The corresponding chances to be improved at the 52 weeks follow-up were 58 % and 40 % respectively.None of the characteristics presented in Table Table p = 0.41; Wald test) and pain related disability  during 1 year follow-up (not in table). Further, no disparities were found in gender stratified analyzes of pain intensity  and pain related disability  (not in table). Figure The joint test of difference – in the GEE framework taking repeated measurements at 7, 12, 26 and 52 weeks into consideration – showed no differences in effect between the three treatment arms, concerning the chance to have a MCI in pain intensity  and pain related disability  (not in table). Figure The joint test of difference – in the GEE framework taking repeated measurements at 7, 12, 26 and 52 weeks into consideration –showed no disparities between the treatment arms regarding mean score in pain intensity  (not in table).Concerning perceived recovery, in the GEE framework taking repeated measurements at 7, 12, 26 and 52 weeks into consideration –no differences in effect between the treatment arms were shown  and NMT excluding spinal manipulation and NMT excluding stretching respectively were found over 1 year concerning MCI in pain intensity and pain related disability or perceived recovery for patients seeking care. Neither were there significant differences in effect in gender stratified analyses. Furthermore, there were no clear differences between the treatment arms during the 1 year follow-up regarding care seeking for their back/neck pain; the proportion that had not sought additional care the presiding three months at the 12 months follow-up was the same (61 %) in all three treatment arms. The findings from this study are similar to findings in some previous studies , 30, 31.n = 1057) which is optimal for the research question addressed. We had a low attrition rate which was equally distributed between the treatment groups . The mean number of previous naprapathic treatments for the patients in the present study was 1.9 (SD = 0.9) compared to 2.5 (SD = 0.7) for those visiting other clinics. Additional parameters like physical activity, pain and disability scores and educational level were equal in the two populations (unpublished data by Joakim Ahlgren).There is an ongoing discussion about if treatment with some of the manual techniques used by manual therapists is associated with a higher risk of adverse events, and if such an increased risk is relevant for the potential benefits in effect of the treatment. The results of this study suggest that exclusion of spinal manipulation or stretching from combined manual therapy do not have a significant effect on improvement in pain intensity, in pain related disability and in perceived recovery in short and long term for patients seeking care for unspecific back and/or neck pain. In our previously published study  based onThese findings might be of importance for patients and for manual therapists when choosing treatment strategies for non-specific neck and/or back pain, even though the result might be limited to treatments given by students. It might not be of importance if we use spinal manipulation and/or stretching strategies when we use combined manual therapy to treat unspecific back and/or neck pain on a group level, and therefore the choice of techniques can be based also on clinical and clinicians indications and patient preferences.The effect of manual therapy including spinal manipulation, mobilization, stretching and massage for male and female patients seeking care for neck and/or back pain at an educational clinic is similar regardless if spinal manipulation or stretching is left out as a treatment option.The trial was approved by the Ethical review board in Stockholm, Sweden, 2009/1848-31/2. Informed consent was received from all study participants including consent for publication of the results.Not applicable.The dataset supporting the conclusions of this article is stored at the Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden, and the primary investigator is ES. Data will not be shared or available in an open access repository because the authors have not finished the data analysis yet. If anyone is interested in exploring specific issue, please contact ES.