The use of opioid analgesics for postoperative pain management has contributed to the global opioid epidemic. It was recently reported that prescription opioid analgesic use often continued after major joint replacement surgery even though patients were no longer experiencing joint pain. The use of epidural local analgesia for perioperative pain management was not found to be protective against persistent opioid use in a large cohort of opioid-naïve patients undergoing abdominal surgery. In a retrospective study involving over 390,000 outpatients more than 66 years of age who underwent minor ambulatory surgery procedures, patients receiving a prescription opioid analgesic within 7 days of discharge were 44% more likely to continue using opioids 1 year after surgery. In a review of 11 million patients undergoing elective surgery from 2002 to 2011, both opioid overdoses and opioid dependence were found to be increasing over time. Opioid-dependent surgical patients were more likely to experience postoperative pulmonary complications, require longer hospital stays, and increase costs to the health-care system. The Centers for Disease Control and Prevention emphasized the importance of finding alternatives to opioid medication for treating pain. In the new clinical practice guidelines for back pain, the authors endorsed the use of non-pharmacologic therapies. However, one of the more widely used non-pharmacologic treatments for chronic pain (namely radiofrequency ablation therapy) was recently reported to have no clinical benefit. Therefore, this clinical commentary will review evidence in the peer-reviewed literature supporting the use of electroanalgesia and laser therapies for treating acute pain, cervical (neck) pain, low back pain, persistent post-surgical pain after spine surgery (“failed back syndrome”), major joint replacements, and abdominal surgery as well as other common chronic pain syndromes . Pain is a common cause of disability and is extremely costly to society at large. The excessive reliance on opioid analgesics for treating both acute and chronic pain has contributed to the current global opioid epidemic. Recently, the Centers for Disease Control and Prevention (CDCP) reported that patients initially given a 1-day supply of opioid medication after surgery had a 6% likelihood of still using the drug a year later. However, that number rose to roughly 10% for patients given a 2-day supply and 45% for patients given a 40-day prescription. In light of the growing opioid crisis, we have emphasized the importance of using non-opioid analgesic drugs and techniques for acute and chronic pain management4. In an accompanying editorial1, we argued that “less may be more” with respect to the use of opioid (narcotic) analgesics for acute (and chronic) pain therapy. Currently, 5–8 million people in the USA use opioids for chronic pain management5. It has become increasingly apparent that prolonged opioid use is a growing problem in previously opioid-naïve patients who receive narcotics for acute pain after a surgical procedure. Excessive reliance on opioid analgesics for postoperative pain control can lead to prolonged opioid dependence after both major6 and minor7 surgery. In a large retrospective study involving over 390,000 older outpatients undergoing minor ambulatory surgery procedures7, older patients receiving prescription opioid analgesics within 7 days of discharge were 44% more likely to continue using opioids 1 year after surgery. More recently, Goeslinget al.6 reported that for many patients taking opioid analgesics before major joint replacement surgery, as well as opioid-naïve patients undergoing arthroplasty procedures, opioid use persisted after surgery despite the absence of joint-related pain. More recently, Cauleyet al.8 reported on a large cohort of opioid-naïve patients undergoing abdominal surgery who continued to use opioid analgesics 3–6 months after surgery. Moreover, adjunctive use of epidural local analgesia was not protective against persistent opioid use in this opioid-naïve population9. Although opioid-related side effects  are well known, there are growing concerns regarding long-term physical dependence and addiction liability with continued opioid use after surgical procedures. In 2007, a review article by international experts in pain management encouraged the more widespread use of opioid-containing analgesics for treating chronic pain by suggesting that “if only we  could overcome our ‘opiophobia’, we would improve pain management”10. Interestingly, no study of prolonged opioid use has ever demonstrated long-term benefits for the users. An epidemiological study by Eriksenet al.11 involving patients with chronic pain treated with opioids for 5 years provided compelling evidence that opioids were not a panacea for chronic pain. In fact, the patients’ quality of life failed to improve despite escalating doses of opioids over the 5-year study period. The authors concluded that “it is remarkable that opioid treatment of long-term/chronic non-cancer pain does not seem to fulfil any of the key outcome treatment goals, namely pain relief, improved quality of life and improved functional capacity”11. More recent studies suggest that long-term opioid use can actually retard functional recovery. In a 2012 commentary, Sullivan and Ballantyne12 asked the rhetorical question, “what are we treating with long-term opioid therapy?” As the opioid epidemic continues to spread and deaths due to opioid overdoses increase, it is clear that the only “winners” are the pharmaceutical drug manufacturers.Prolonged use of opioid analgesics is associated with an increased risk of more serious complications, including opioid use disorder, overdose, and deathTime magazine described a new paradigm for treating opioid addiction13. Predictably, the solution being offered by the pharmaceutical industry involves giving more drugs! The “new” drug touted as the solution to opioid dependency (Suboxone) is a combination of two old drugs, namely buprenorphine  and naloxone (an opioid antagonist). A more recent article14 describes the cost of the “follow on” drugs used to counteract opioid-related side effects  and overdoses. In 2016, US pharmaceutical companies had sales of $8.6 billion on 336 million opioid prescriptions. The “follow on” drug market is currently valued at more than $3 billion per year, and sales of drugs used to counteract opioid-induced constipation exceed $2 billion per year14. It is time to seriously consider the use of “alternative” non-pharmacologic therapies for treating chronic pain rather than simply giving more opioid compounds and hoping for a different result3.A 2016 article in15, Oz and Olivo16 suggested that it was time to consider incorporating complementary and alternative medical practices into conventional medical treatments. Other studies have suggested that perioperative imagery, massage, and music can reduce pain and anxiety after surgery18. A 2007 editorial on the potentially beneficial role of “alternative” therapies as part of a multimodal approach for reducing anxiety, pain, and emetic symptoms in the perioperative period19 suggested that it was time for practitioners to “get on board” by incorporating non-traditional medical therapies into their everyday clinical practices. Sadly, 10 years later in the face of an opioid epidemic, the emphasis of the medical community remains on pharmacotherapy. In this F1000 Faculty Review, we discuss clinical studies describing the benefits of using electroanalgesia and laser therapy as adjuvants in the management of acute and chronic pain.Given the fact that the long-term use of opioid analgesics fails to improve the lives of patients suffering from chronic pain and costs the health-care system billions of dollars to treat opioid overdoses, it is somewhat surprising that the health-care practitioners (and third-party payers) have been reluctant to seriously consider the use of non-pharmacologic “alternative” therapies for managing pain. The use of non-pharmacologic modalities has been questioned by medical practitioners because of the perceived lack of prospective, randomized, double-blind sham-controlled studies supporting their use in clinical practice. Although this skepticism may be warranted for some so-called alternative pain therapies, there are in fact many well-controlled studies confirming the benefits of using electroanalgesia and laser therapy for improving acute and chronic pain management. Nevertheless, these non-pharmacologic analgesic modalities remain grossly under-utilized in clinical practice. In a 2006 clinical commentary regarding a study involving the use of complementary alternative therapies for reducing postoperative pain after open heart surgery21. However, the risk of mechanical failure, infection, and neurologic complications, as well as the high costs, are strong deterrents to using this highly invasive electro-analgesic technique. The less invasive forms of electroanalgesia  have been reported to produce significant short-term reductions in the levels of acute and chronic pain and should be used prior to even considering the use of an implantable device.Electroanalgesia is a form of neuromodulation therapy which encompasses electro-acupuncture (EA), ultrasound-guided acupotomy, percutaneous electrical nerve stimulation (PENS), transcutaneous electrical nerve stimulation (TENS), and peripheral nerve stimulation (PNS). Patients who experience significant improvement in pain and disability with PNS may be candidates for implantation of a spinal cord stimulatoret al.22 reported that TENS applied at acupoints reduced both postoperative pain and emesis, confirming earlier studies27. TENS also reduced pain and improved patient satisfaction during minor office procedures28. However, in a comparison of TENS and parasternal local anesthetic blocks for pain management after cardiac surgery29, the local anesthetic-based technique was found to be significantly more efficacious. TENS produced modest short-term reductions in pain and improvements in physical activity in patients experiencing a variety of chronic pain syndromes . However, a recent review of electrotherapy modalities for treating chronic rotator cuff diseases42 concluded that, in contrast to more invasive electroanalgesia modalities , TENS was not consistently superior to placebo treatments. In patients undergoing total knee arthroplasty procedures, TENS offered no significant advantage with respect to improving pain control and functional recovery compared with placebo treatments43. Finally, Salazaret al.44 recently reported that there was only low-quality evidence supporting the effectiveness of TENS for pain relief in patients with fibromyalgia. However, these investigators found moderate-quality evidence for the effectiveness of EA in treating fibromyalgia-related pain44. Thus, the current evidence suggests that TENS techniques are significantly less effective than electroanalgesia techniques such as EA and PENS, which involve the insertion of multiple acupuncture-like needles45.Ganet al.31 and others32 have reported on the short- and long-term benefits of EA in patients with chronic low back pain. In a recent study involving elderly patients undergoing spine surgery, Zhanget al.46 found that preoperative EA (versus “sham” treatments) reduced both intraoperative anesthetic and analgesic requirements, levels of inflammatory mediators, and residual postoperative cognitive dysfunction in elderly surgical patients. These EA studies are consistent with studies involving the use of PENS in patients with chronic low back pain47 and sciatica33. Moreover, PENS was found to be significantly more effective than TENS and exercise therapy47. In a recent comparative study, PENS was found to be more effective than “dry needling” in improving pain control in patients with myofascial chronic neck pain48. A growing body of literature supports the short-term benefits of EA and PENS techniques when administered as an adjuvant to conventional medical approaches in the management of a wide variety of acute and chronic pain syndromes, including post-surgical pain, low back pain, sciatica, neck pain, knee osteoarthritis, headaches, peripheral neuropathic pain, and fibromyalgia52. In a recent comparative study, EA was also found to be more effective in facilitating functional recovery in patients with knee osteoarthritis than the potent non-steroidal anti-inflammatory drug meloxicam53. Interestingly, acupotomy EA was reported to be superior to conventional EA in patients with knee osteoarthritis with respect to pain control and functional recovery54. Despite numerous controlled studies in the peer-reviewed literature supporting their clinical efficacy -approved for treating pain in 2001, and low-level laser therapy (LLLT), also known as cold laser therapy, has been used in the USA since only 2002. High-intensity laser therapy (HILT), also known as laser heat therapy, is an even more recent development; initial publications appeared in 2011. Laser therapy involves a simple, non-invasive, “point-and-shoot” technique which can be performed by technicians. Cellular chromophores are presumed to be the receptor sites responsible for the beneficial effects of the laser light beam, including both cytochrome c oxidase (with absorption peaks in the near-infrared range) and photoactive porphyrins66, nipple pain associated with prolonged breastfeeding67, plantar fasciitis69, and carpel tunnel syndrome70). In women with chronic myofascial pain, LLLT reduced the pain intensity71. Interestingly, LLLT has been reported to reduce acute pain after coronary artery bypass graft surgery73. Recent studies also reported that LLLT could improve sensory function in patients with peripheral somatosensory neuropathy and neuropathic pain75. However, other investigators have reported sham-controlled studies with negative results using LLLT in patients with superficial medical conditions 76. Despite early clinical studies reporting benefits from LLLT in patients with fibromyalgia78, a recent study by Vayvayet al.79 reported that LLLT was not significantly better than sham treatments and Kinesio Tape.Many sham-controlled studies have reported that LLLT is effective in alleviating acute pain associated with a variety of superficial medical and surgical conditions . Although LLLT has been reported to have a suppressive effect on cancer cells97, studies using rodent models suggest that it might modify cancer cell behavior and actually lead to stimulation of dysplastic cells101. For example, Rheeet al.102 reported that LLLT increased tumor size in rodents when thyroid cancer cells were directly exposed to photodynamic (laser) therapy. Clearly, additional studies with both LLLT and HILT are needed in patients with cancer.LLLT has been reported to be a useful adjunct treatment for oral mucositis in patients with canceret al.103 concluded that LLLT produced a “moderate” reduction in pain while improving the patients’ perception of clinical benefit and level of functionality. Glazovet al.104 found evidence to support a short-term benefit of LLLT in treating low back pain in patients with a shorter duration of pain symptoms. However, these investigators suggested that greater pain-relieving benefits were achieved when higher laser dosages were administered . This speculation was confirmed by Boyrazet al.105 and Chenet al.106, who reported that HILT in combination with exercise produced significant functional improvements with longer-lasting beneficial effects than exercise therapy alone in patients with lumbar disc herniation. HILT also appeared to be an effective alternative to spine surgery for reducing pain and improving the performance of activities of daily living in patients with chronic back pain107.In a sham-controlled, prospective safety and efficacy study of LLLT in patients with subacute musculoskeletal back pain, Basford42, the authors stated that LLLT has only short-term benefits (versus sham) in treating rotator cuff disease; however, HILT was effective in minimizing pain and disability and increasing range of motion in patients with shoulder pain108. Similarly, in a 2013 systematic review of LLLT in treating chronic neck pain, the authors reported that although the benefits observed were statistically significant, the differences failed to achieve a “minimally-important clinical difference”109. In contrast, Alayatet al. found that HILT combined with exercise in patients with chronic low back110 and neck111 pain was more effective than exercise therapy alone and also had a more sustained effect in decreasing pain and functional disability , and beneficial effects lasted for up to 3 months. Chowet al.112 reported that laser therapy reduced pain immediately after treatment sessions in patients with acute neck pain and for up to 22 weeks after completion of a series of treatments in patients with chronic neck pain. Haładajet al.113 demonstrated that HILT also produced clinically-significant analgesic efficacy in patients with cervical radicular pain syndrome and cervical spondylosis. Dundaret al.114 reported that HILT is an effective therapeutic method in the treatment of patients with myofascial pain syndrome of the trapezius muscle, a common cause of chronic neck pain.In a recent reviewet al.115 and others116 reported that HILT was an effective non-surgical intervention for patients with knee osteoarthritis, reducing pain and improving their ability to perform activities of daily living. Alayatet al.117 reported that, in men with osteopenia and osteoporosis, HILT combined with exercise was more effective than exercise alone in reducing pain and improving quality of life after a series of treatments. Kheshieet al.118 and others119 have reported that HILT is significantly more effective than LLLT in treating chronic osteoarthritis-related pain. These findings with HILT (versus LLLT) were also confirmed in a study by Alayatet al.120 in patients with Bell’s palsy. HILT was also effective in the short-term management of pain and disability related to subacromial impingement syndrome, frozen shoulder and lateral epicondylitis123. HILT at wavelengths of 830 and 1,064 nm was better than TENS in improving control of pain and paresthesias secondary to carpal tunnel syndrome124. Analogous to LLLT, HILT has also been used to treat acute headache pain127, degenerative joint conditions131, neuropathic pain syndromes136, and a wide variety of musculoskeletal disorders, including fibromyalgia137.Kimet al.138 demonstrated that the beneficial outcomes of laser therapy were directly related to the amount of energy (power) administered. The energy density (in joules per square centimeter) or power (in watts) appears to be strongly related to the efficiency of laser radiation in reducing pain and inflammation. Power density represents the laser/light-emitting diode incident power in watts on the tissue spot size . The higher power density is responsible for regulating or “speeding up” the transport of electrons in the mitochondrial respiratory chain90. The World Association of Laser Therapy has established that target tissues need an energy density of 5–7 J/cm2 or higher to elicit a clinically significant biological cellular response139.A more powerful version of HILT has been introduced using class IV lasers producing more than 25 W of power  . Huange140. In addition, some of these powerful laser devices function at longer wavelengths; for example, the Phoenix Thera-Lase , which produces up to 75 W of power, operates at a wavelength of 1,275 nm. Therefore, the laser beam produced by these devices can penetrate more deeply into the soft tissue because of their enhanced power and the reduced absorption of the laser beam by melanin and hemoglobin  reduces low back pain scores and disability at 1, 2, and 4 months post-treatment. The greatest efficacy in promoting nerve regeneration and modulating pain transmission was associated with the use of the longer wavelengths .Super-pulsed class IIIB lasers  can produce a peak power of up to 100 W without causing tissue warming in contrast to the more powerful class IV lasers . In a sham-controlled study, Leal-Junior and colleagues150, the US Surgeon General pointed out that the annual number of overdose deaths involving prescription opioids has nearly quadrupled since 2000 and this increase parallels the marked growth in the quantity of opioid pain relievers being prescribed151. Prescription opioid addiction and misuse have also contributed to a resurgence in heroin use and the spread of HIV and hepatitis C152. In the “Turn the Tide” Rx Pocket card which the government recently mailed to all practicing clinicians in this country, there was no mention of non-pharmacologic approaches to treating pain. However, in the recent FDA response to the opioid crisis, Califfet al.153 emphasized that more “alternatives” to opioid analgesics are needed, including non-pharmacologic therapies. According to the FDA leadership, “non-pharmacologic approaches to pain treatment were identified as an urgent priority”153. The new Clinical Guidelines Committee of the American College of Physicians also endorsed the use of non-invasive treatments such as laser therapy for the treatment of acute, subacute, and chronic low back pain154. The CDCP has also recently emphasized the importance of finding non-pharmacologic alternatives to opioid analgesic medications for treating pain155. These authors reported that patients initially given a 1-day supply of opioid medication had a 6% likelihood of still using the drug a year later. However, that number rose to roughly 10% for patients given a 2-day supply and to 45% for patients given a 40-day prescription.In a recent “call to action” to end the opioid epidemic in this countryet al.156, in a recent issue of theNew England Journal of Medicine, reported that long-term opioid use was increased in previously opioid-naïve patients who received treatment in an emergency department from high (versus low) intensity opioid prescribers. Altering the prescribing habits of physicians and their surrogates will clearly help; however, in order to effectively deal with the current opioid crisis, more innovative non-pharmacologic approaches for treating acute and chronic pain are clearly needed157. In this review, we have described numerous clinical studies published within the last 5 years which support the use of non-pharmacologic electro-analgesic and laser therapies for managing both acute and chronic pain.Of importance, Barnett158 and infrared light160, respectively. Acustimulation, a popular form of electroanalgesia, has been reported to trigger the release of neurotransmitters and endogenous opioid-like substances and to activate c-fos within the central nervous system (CNS). Laser photobiomodulation appears to induce direct inhibitory effects on peripheral nerves, which reduces acute pain input into the CNS. In chronic pain patients, laser-induced changes in the spinal cord produces longer-term suppression of pain in the CNS.The consequences of the widespread reliance on opioid-containing medication for managing acute and chronic pain should not be surprising. Many different electro-analgesic and laser therapy techniques have been described in the peer-reviewed literature for treating acute and chronic pain. However, these “alternative” therapies have failed to achieve broad acceptance in the medical community because of lingering questions regarding their analgesic efficacy, a lack of long-term outcome studies, and low reimbursement by third-party payers to the health-care providers administering these non-traditional therapeutic modalities. Although the use of powerful HILT devices appears to produce more profound and sustained beneficial effects than electroanalgesia and LLLT in the treatment of acute and chronic pain, this therapeutic modality has also failed to achieve widespread acceptance in the medical community because of a lack of knowledge regarding the potential long-term benefits of HILT among health-care providers, low third-party reimbursement rates, and the high cost associated with purchasing these more powerful laser devices. The mechanism of action of both electroanalgesia and laser therapy appears to involve neuromodulation of peripheral nerves using low-level electrical currentsGiven the current opioid crisis in the USA, it is time to seriously consider incorporating these “alternative” analgesic therapies into treatment protocols for managing acute and chronic pain rather than adding more “fuel to the fire” by administering even more opioid-related drugs (157). A simple, safe, and effective non-invasive pain therapy without side effects could significantly reduce the dependence on oral opioid-containing medications in the post-discharge period after surgery. These non-pharmacologic therapies would also be cost-effective alternatives to opioids for treating chronic pain not responding to non-opioid analgesic medications. It would appear that both electroanalgesia and laser therapy are safer and more cost-effective for managing chronic pain than the long-term use of opioid analgesics. Finally, HILT could prove to be a valuable therapy for treating patients who have become addicted to opioid-containing prescription medications.


Central sensitization (CS) is regarded as an important contributing factor for chronification of musculoskeletal pain (MSP). It is crucial to identify CS, as targeted multimodal treatment may be indicated. The primary objective of this study was therefore to explore pain experience of individuals with MSP+CS in order to gain a better understanding of symptoms in relation to CS from a patient perspective. The secondary objective was to investigate whether pain experiences of patients with MSP+CS differ from those of individuals with neuropathic pain (NP).We conducted a comparative Group Delphi Study including patients with MSP+CS and neuropathic pain (NP). 13 guiding questions were used to gather information about sensory discriminatory, affective and associated bodily, mental and emotional phenomena related to the pain experience of patients. Descriptions were categorized using qualitative content analysis. Additionally, patients completed several pain related questionnaires.Nine participants with MSP+CS and nine participants with NP participated. The Delphi procedure revealed three main themes: psycho-emotional factors, bodily factors and environmental factors. Descriptions of patients with MSP+CS showed a complex picture, psycho-emotional factors seem to have a considerable impact on pain provocation, aggravation and relief. Impairments associated with mental ability and psyche affected many aspects of daily life. In contrast, descriptions of patients with NP revealed a rather mechanistic and bodily oriented pain experience.Patients with MSP+CS reported distinct features in relation to their pain that were not captured with current questionnaires. Insight in patient’s pain experience may help to choose and develop appropriate diagnostic instruments. Musculoskeletal pain (MSP) such as low back, neck or shoulder pain is the most common reason for pain in general and contributes significantly to health related costs in western industrialized countries, second only to cardiovascular diseases . While mSo far, no gold standard exists to diagnose CS. Even for elaborated but costly and time-consuming procedures such as quantitative sensory testing or laser-evoked potentials there are no generally agreed and diagnostic cut-off values. Thus, clinicians commonly rely on signs, symptoms as well as clinical examination to identify CS . In a reThe above mentioned symptoms and signs are based mainly on the perspectives of clinicians and/or researchers and contain multiple subjective components based on clinical judgement. In regards to the broad impact of CS in the genesis and maintenance of chronic musculoskeletal pain, it seems important to gain more detailed information about pain experience from the perspective of individuals with MSP+CS. This information may be valuable to determine patient preferences and values and to help guide the use or development of questionnaires assessing the domain of central sensitisation.The primary objective of this study was therefore to explore pain experience and understanding of individuals with MSP+CS. The secondary objective was to investigate whether pain experiences of patients with MSP+CS differ from those of individuals with neuropathic pain (NP).LJ, KW, KR and SN conducted the Delphi rounds. The interviewers were all female and trained physiotherapists (BSc), with a median experience of 8 (IQR 4.5) years in the treatment of musculoskeletal or neurological patients. The interviewers and AS were not known to the participants until the start of the study, FP as head of the pain clinic was known to the participants from consultation and treatment, but was not involved in the data collection process. The conduction of the study was supervised by AS and FP.A qualitative cross-sectional study with two groups  was conducted. Data was collected by adapting the Delphi-technique for groups. The Delphi-technique for groups is an explorative approach to determine unknown information and represents a discursive process to gather information about a topic, which is relevant to the participants of the study . The aimEthical approval for this study was obtained from the Human Research Ethics Committee, Universitätsmedizin Göttingen (Nr. 18/9/11) in accordance with the Declaration of Helsinki on Ethical Principles for Medical Research Involving Human Subjects. All subjects provided written informed consent to participate.A convenience sample of nine patients with musculoskeletal pain and central sensitization and nine patients with neuropathic pain were recruited from active patients in a multidisciplinary and tertiary pain clinic. All patients considered had undergone thorough clinical and psychological diagnostics at admission and were treated for at least six months at the institution. The diagnostic psychological interview was conducted by a trained psychologist (MP) specialized in treating patients with chronic pain, the clinical assessment by a pain specialist MD. Patients had received different treatments ranging from purely medication interventions to participation in the pain clinic’s multimodal treatment program (five in group MSP+CS and two in NP). Active patients were reviewed by MP and FP and approached if likely to fulfil the inclusion criteria for either group. They were then re-evaluated by FP and MP and recruited, if in-criteria were fulfilled and no exclusion criteria present. Since the aim was to recruit two groups of “representative” patients in terms of the selected criteria and not a representative overall sample no detail on excluded patients were collected (see limitations of the study in the Discussion section). Participants had to be between 18 and 80 years of age and either have a diagnosed musculoskeletal (MSP + CS) disorder or neuropathic pain disorder (NP). Specific exclusion and inclusion criteria for the group MSP+CS are shown in Inclusion criteria for the group Neuropathic Pain were:Age between 18 and 80Definite neuropathic pain according to Exclusion criteria for both groups were the clinical diagnosis of a somatoform pain disorder based on the initial diagnostic psychological interview on pain clinic admission and re-evaluation. The psychological interviews were conducted by a trained psychologist specialized in treating patients with chronic pain (MP).Central to the Delphi-technique are questions that are used to maintain the focus of the discussion on pain experience and to ensure consistency across groups. To generate questions, a systematic literature search was conducted, searching the databases Medline, Cinahl, Cochrane, PEDro, Sport Discus and the following journals: Pain, physioscience, Manuelle Therapie, Spine and Rheumatologie. Search terms were: AND 43 relevant articles were screened for pain dimensions and descriptions. The most frequent ones were discussed within the research team to reach consensus. A list of key questions was derived to cover the identified dimensions and descriptions with 13 questions concerning sensory discriminatory (Q 1–12) and associated bodily, mental, emotional and activity related phenomena (Q 13a-d) of central sensitization . The lisThe Delphi procedure took place during a one-day session at a multimodal pain clinic from 9am 5pm, with appropriate breaks between the data collection sessions. Patients with MSP+CS and patients with NP participated separately on two different occasions. To the knowledge of the investigators there was no communication or interaction between patients of the two groups. The research team had no information on the clinical diagnosis of the participating patients beyond their overall group assignment.Data collection followed a structured and standardized procedure . There wData was collected in two rounds. During the first round (90 Minutes) the questions were discussed. The aim was to collect as many subjective pain-describing items from individual participants as possible. Besides, the participants were asked to draw the location and expansion of their pain into a body chart and to report quantitative aspects of their pain experience such as pain intensity or duration of pain .For the second round of data collection participants were allocated randomly to new groups. Patients were asked to rate the various items from the first round by using a Likert-Scale from 0 to 10  . After tFinally, all nine participants could ask questions, make comments and were informed about the further procedure. They received the final item list including the ratings to take home. Participants were asked to reflect on the results and make changes or comments if applicable and to post the commented list back to the research team.To gain further information, patients additionally completed the following questionnaires on another occasion. This data collection was scheduled a few weeks after the survey to not influence the patient’s subjective performance by providing a range of predefined possible answers.Based on a body diagram the area marked as painful was scored from 0–19 following the regions described in the regional pain scale Pain Sensitivity Questionnaire (PSQ)  measuresTampa Scale of Kinesiophobia  a questiPain Perception Scale (SES)  measuresDepression Anxiety Stress Scales (DASS)  screens Patient Health Questionnaire (PHQ)  evaluatePain Detect Questionnaire  screens Pain Catastrophizing Scale (PCS)  a questiSF-36  measuresDescriptions of the course of pain were visualised in seven different graphs. Quantitative data (Q1a-c) from round one was summarized by calculating the median and interquartile range (IQR) as well as arithmetic mean and standard deviation (SD).Means were also calculated for the collective ratings of the qualitative data (Q4-13) from round two. These mean ratings were used to reduce the number of items; all items with a mean rating below 3/10 as well as duplicates were removed. To analyse pain descriptions, a qualitative content analysis according to Mayring  was condQuestionnaire data was compared between groups using non parametric statistics (Mann-Whitney-U-Test), since n was too small to assess normal distribution . For theData collection took place during two Delphi sessions. In the first session nine patients with MSP+CS participated, consisting of eight females and one male who had the following diagnoses: fibromyalgia (n = 2), spinal pain (n = 3), chronic widespread pain (n = 4). Patients with spinal pain had non-specific pain progressing beyond the initial low back or neck pain (but not radicular pain), patients with chronic widespread pain had no other specific diagnosis, except for mild and non-specific degenerative changes. Median age was 49 years (IQR = 6).In the second session nine patients  with NP participated, median age was 57 (IQR = 19). Patients in the group NP had the following diagnoses: neuralgia (n = 4), polyneuropathy (n = 4) and radiculopathy (n = 1). For details see The results of the completed questionnaires are summarized in Scores for subjective sensory and affective pain sensation measured with the pain sensation scale (SES)  were lowMean Depression subscale (DASS) was below the cut off score in both groups , howeverSix patients of seven in the NP group had Pain Detect (PD) scores >18 indicating a likely neuropathic pain component, compared to four out of eight in the MSP+CS group. For the rest of the patients a neuropathic pain component was uncertain with PD scores between 12 and 18. For none of the participants a neuropathic pain component could be excluded (PD score <12) .Patients in both groups exhibited impaired general physical health with SF36 physical component summary 1.71 SD (MSP+CS) and 2.05 SD (NP) below the norm . Mental The results of the Delphi procedure are summarized in Patients in the MSP+CS group reported painful areas all over the body. In the body charts they marked eight to twenty painful areas, which often had a widespread extent. Patients in the NP group marked one to three pain regions in the body charts. These reflected the underlying neuropathic disorder.The median highest experienced pain in the last week on an 11-point NRS was 7 (IQR 1) for the MSP+CS group and 8 (IQR 2) for the NP group. The lowest experienced pain of the last week was 3.5 (IQR 1) for group MSP+CS and 4 (IQR 2) for group NP. The patients had median pain intensity during the last week of 5 (IQR 2) in the MSP+CS group and 7 (IQR 2) in the NP group. Participants in both groups typically described constant pain . Answers concerning pain duration also showed that both NP and MSP patients experience constant pain.While the intensity of pain seemed to be similar (Mann Whitney U Test p>0.26) and both groups reported a constant component in their pain, the course over time differed between the two groups. Whereas the NP group typically reported constant pain with peaks like “flashes” or “electric shocks”, the MSP+CS group described the pain as a constant pain with waves that seemed to last longer than the peaks of the NP group. This was in line with the use of items that indicate differing variability of pain: “interval” (NP) or “depending on the situation” (MSP+CS), “repeated bouts of 10–30 seconds duration” (NP) or “a few seconds up to four hours” (MSP+CS).In both groups participants described characteristics of their typical pain. Two main categories could be derived: pain quality and affect.For patients in group NP the most relevant subcategories for pain quality were shooting 6.73 (i.e. “fulgurant pain” 7.5), burning (6.3) and dull (6.0). Most relevant descriptions in the category affect (8.0) for patients with NP were “nasty” (9.7) and “nerving” (9.0).Pain descriptions in group MSP+CS were more numerous (33 vs. 17) and could be categorized in more subcategories (11 vs. 8) compared to patients with NP. Most relevant subcategories for patients with MSP+CS were radiating (7.7), burning (6.9) and shooting (6.75). The category affect (7.63) included pain descriptions such as “tormenting” (8.4).To investigate patient’s pain experience in regards to influencing factors, three questions were asked: “what triggers the pain?” “what relieves the pain?” and “what aggravates the pain?” .Patients with NP reported pain triggers /Q6) that could be categorized as bodily factors (4.9). Subcategories were motor stimuli (4.9) such as “physical load” (5.5) and sensory stimuli (4.9) such as “unsuitable shoes” (5.0). In group MSP+CS psycho-emotional trigger were most important (6.8), patients mentioned intrinsic factors such as “to put oneself under pressure” (8.2) and extrinsic factors like “lack of time” (8.2) or “excessive demands” (8.2). Patients in the MSP+CS group mentioned a total of 14 different items in the category psycho-emotional pain trigger compared to one item in group NP.In group NP the participants mentioned “medication” (9.3) as the most important pain relieving factor (Q7). Patients in the MSP+CS group stated that physical therapy (8.2), physical stimuli such as “bathtub” (9.5) or “hot springs” (9.7) and relaxation such as “relaxing music” (8.0) were most relevant, also “medication” (6.2) and motor activity i.e. “aqua-fitness” (6.2) were mentioned. Overall, passive activities such as “bathtub” or “hot springs” received the highest rating in regards to pain relieve in group MSP+CS. In contrast, patients in the NP group also expressed active strategies such as “doing joyful things” (4.7) or “change of activity” (3.7) to reduce pain.The category psycho-emotional factors was more highly rated (6.4) in the MSP+CS group compared to the NP group (3.8). This observation was further emphasized when comparing the total number of items mentioned: 27 items for psycho-emotional factors in group MSP+CS and 3 items in group NP.In regards to factors that aggravate pain (Q8), experiences differed between the two groups. For patients in group NP the most relevant category was bodily factors such as physical strain (i.e. “standing for a long time” (5.7). Also relevant in the NP group was the statement “no pain aggravating factors” (4.0). Furthermore, context factors (3.7) were mentioned such as “cold” (3.3). Psycho-emotional factors were less relevant for patients with NP with a mean rating of 3.1.In comparison to group NP, Patients in the MSP+CS group mentioned a greater number of possible factors that might aggravate pain . Psycho-emotional factors (6.5) were the most relevant pain aggravating factors for the MSP+CS group with high mean ratings and a large number of items. Examples for descriptions in this category are “emotional distress” (8.0) or “to take things to much to the heart” (7.2). Patients also described personal factors (6.8) such as “working more than one has to” (8.2) and environmental factors (6.1) (i.e. “excessive demands” 7.8) and context factors (6.9) such as “cold” (9.0) or “the job” (4.8).In answer to the question “how did your pain change since the beginning of your problem?” patients in both groups reported improvement as well as worsening. Improvement based on endogenous factors such as “I have learned to deal with my pain (through therapy)” was reported. Worsening of pain was described in terms of a spread of pain without explainable cause in both groups.Patients in both groups (NP and MSP+ CS) reported signs of allodynia in relation to stimuli, movement and activities. Mean ratings for descriptions related to allodynia were higher in group MSP+CS compared to group NP. Perception of normally non painful stimuli as painful  such as punctual touch (MSP+CS 7.5) or pressure and strain (NP 6.0) were reported. A second category in both groups was movement related allodynia  associated with posture, movement and movement under load.Participants in group NP did not describe any signs of hyperalgesia. Patients with MSP+CS mentioned that “to stub against something” (7.7) was more painful than before the start of the problem. Patients in both groups stated that they are less sensitive to painful stimuli compared to the beginning of their problem.Questions about associated phenomena in relation to the body, mental ability, psyche and activities of daily living were asked to gain insight into patient’s experiences on how pain affected different dimensions of function, activities and participation. Patients were asked to report associated phenomena that developed from the beginning of the disease.Associated phenomena related to the body (Q13a) were categorized as sensory phenomena or as symptoms in body systems. These categories differed in relevance between the two groups. For patients in the group MSP+CS the most important pain descriptions were related to sensory phenomena (7.0) such as temperature (7.3) (i.e. “being cold” 9.7), vision (7.2) (i.e. “hypersensitivity to light” 7.2) or hearing (7.0) (“hypersensitivity to noise” 7.0). Other descriptions related to body systems (6.3) such as the skin (“dry skin” 8.3) or nasopharyngeal zone (i.e. “dry tongue” 6.7).Patients in the group NP reported descriptions mainly in the category body systems (mean 5.4); these were related to the musculoskeletal system .Associated phenomena in regards to mental ability (Q13b) had equal relevance for the patients. Both groups reported lack of motivation , with decreased perseverance  and lack of inner drive . Patients experienced a decrease in vigilance  as a result of fatigue, lack of concentration and memory deficits. Additionally, both groups reported an impaired ability to communicate  affecting both sending (“I can’t remember certain words” MSP+CS 6.7) and receiving information (“I have difficulties listening” MSP+CS 5.3).Patients in both groups described different phenomena associated to psychological aspects (Q13c). Patients in group MSP+CS provided more descriptions compared to patients in group NP. These were predominantly negative changes in relation to thoughts (6.3) (i.e. “not being able to stop brooding” 6.7), lack of motivation (6.0) (i.e. “this is the bottom line” 6.8) and emotions (5.5) (“being more sensitive” 7.3).Patients in group NP also reported positive changes in regards to their attitudes (4.6) and motivation (3.0) such as “priorities have changed” (6.7) or “I have so much energy that I can manage anything” (3.0).Patients in both groups reported impairments in their activities of daily living  such as employment or housework  (i.e. “I had to slow down” MSP+CS 7.7 or “I can’t work as many hours as I would like to” NP 7.3), hobbies (MSP+CS 5.4) and sport activities . Also impairments in regards to social activities with a mean ranking of 5.4 in group of MSP+CS  and 4.3 in group NP (i.e. “I am more cautious to accept invitations” 5.0) were mentioned.Patients with MSP+CS experience constant moderate to severe pain in many body regions. Descriptions of these patients reveal a complex picture of pain manifesting in many dimensions, particularly in regards to emotional and psychological aspects. Exemplary are descriptions of pain trigger, pain aggravating and relieving factors that reveal the importance of psycho-emotional aspects.Pain trigger and pain aggravating factors in group MSP+CS were often external factors such as perceived strenuous work situations. These are factors that cannot be easily influenced by the patients. Consequently, statements in regards to pain reduction in group MSP+CS typically reveal rather passive pain coping strategies.Patients with MSP+CS are affected in many aspects of daily life. In regards to relevant phenomena associated with pain, patients reported impairments in regards to their mental ability, such as reduced motivation, vigilance and resilience as well as impaired ability to communicate. These findings are comparable to the findings of others studies. Turk et al.  reportedOur data show similarities and contrasts of pain perception between patients with MSP+CS and NP. Patients in both groups were severely impaired by chronic pain and both report marked restrictions in their activities of daily living. The quantitative aspects of the pain experience such as intensity, frequency, duration, and time of occurrence were comparable between groups.Contrasts could be shown in relation to sensory and affective aspects of pain. In general, structural and somatic factors in relation to pain triggers, reduction, aggravation and associated phenomena were more relevant for patients in group NP, whereas for patients with MSP+CS affective and emotional factors were most relevant. Associated phenomena related to the body were mainly confined to the musculoskeletal system in group NP, whereas patients with MSP+CS reported symptoms in multiple body systems.This pattern also becomes evident in regards to pain triggers. Patients with NP mentioned mainly pain triggers related to the body. These were generally modifiable by behavioural changes such as avoiding physical strain or changing unsuitable shoes. Patients mainly employed active strategies to reduce pain (“doing joyful things”). This implies higher coping abilities or acceptance of pain related disabilities in the group NP. Patients in group MSP+CS weighted psycho-emotional factors higher when describing pain trigger, reduction and aggravation. This depicts contrasts in pain experience and in the understanding of the nature of pain. Patients with NP showed a rather mechanistic and structural pain understanding that may be enhanced by a more localised and “explainable” pain experience, whereas patients with MSP+CS experienced pain as complex and multifactorial, with a higher weight on psycho-emotional factors. This is further supported by the higher mean number of pain descriptions in all categories in group MSP+CS with 5.3 compared to 3.7 in group NP.Interestingly, these trends to describe pain were poorly reflected in the actual questionnaire data from the two groups, where patients with neuropathic pain reported more affective disturbances. This may indicate that the relationship between affective symptoms and pain perception could differ between patient groups. On the other hand, the pain detect questionnaire and the extent of pain was in line with Delphi results.When comparing questionnaire data with Delphi results, further differences and discrepancies become obvious. In contrast to Delphi results all SF-36 subscales except bodily pain and PCS were within 1 SD of normative population scores. For example, the SF-36 subscales vitality (-0.32 SD) and mental health status score (MCS) (-0.2 SD) were not different to population normative data, although Delphi results clearly showed that patients felt affected in these dimensions. Also in contrast to Delphi findings, SES scores indicated that the emotional burden of pain was 2.84 SD below the norm for pain populations. When comparing Delphi results to questionnaire data limitations of the used questionnaires to capture the complex picture of patients pain experience and understanding become evident. These differing results may also reflect potential positive effects of therapy in the current patient sample that had received various pain management interventions. Thus Delphi results may represent an overall concept of pain and disability these patients have, while questionnaires may reflect the individual’s current status of health and pain.Importantly, patients with MSP+CS had a more extensive spatial extent of pain, which was possibly biased by selection in this sample. However, it has recently been shown that even in a low back pain cohort, many patients report increased spatial extent of pain, when specifically asked for other pain sites . In anotThe Delphi procedure thus has the potential to capture the overall characteristics of the MSP+CS and NP condition in general, irrespective of the current situation of the patients. It stated the relevance of symptom and experiences from the patient’s perspective and not the individual level of symptom intensity as measured by the respective questionnaires. Viewed from this perspective typical clinical perceptions of the two different pain conditions are reproduced and confirmed by the Delphi procedure. On the other hand it becomes obvious how similar the overall burden of pain is for the two groups, which probably is better highlighted by the individual questionnaire data.As expected, more patients in the NP group were classified as “probable neuropathic” based on their painDetect scores , howeverThis discrepancy might be related to properties of the painDetect questionaire. The validation describes selection of items based on the literature and not a patient survey . The iniThe Delphi procedure for groups is a valid method for investigating experiences of experts in relation to a particular problem . ExpertsA second issue relates to the clinical diagnosis of “central sensitization”. An experienced medical pain specialist (FP) made the clinical diagnosis based on predefined criteria. Although the diagnostic criteria for central sensitization  showed rFurther limitations relate to the sample. Firstly, the two groups were not comparable in regards to sex and age. Patients in group MSP+CS were nine years younger on average and had a higher proportion of females , which mFinally, although the sample size of nine per group is within the recommended size for Delphi groups, potential bias like an overrepresentation of patients with widespread pain / fibromyalgia, or a non-representative sample for neuropathic pain in this study  limits the generalizability of the findings to a chronic pain population.The results of the present study illuminate features of a subgroup of patients with musculoskeletal disorders. Firstly, the general impression is, that patients with MSP+CS have a more complex and multifactorial pain experience and understanding, in comparison to a group of patients with NP. Secondly, for patients in group MSP+CS, the affective pain component is most relevant, and pain seems to compromise many different aspects of life and health. Furthermore, patients with MSP+CS are affected by associated phenomena relating to psychological and mental impairments, particularly concentration, vigilance, motivation and communication. These findings are in accordance with other studies , 36, 37


Chikungunya is a severe and debilitating disease. Currently, Brazil is experiencing an epidemic caused by three arboviruses, which has changed the way health professionals have diagnosed and treated infected patients. The difficulty of diagnosis and the lack of a protocol for patient treatment, which fits Brazilian health system models, have made it difficult to manage this disease. It is necessary to implement a multidisciplinary network of patient care, in which primary care units play the main role. This review aims to present current information regarding the clinical aspects and treatment of Chikungunya virus infection. Aedes mosquitoes. The virus was first described in 1952 during a febrile illness outbreak in Makonde, a province in southern Tanzania (Chikungunya virus (CHIKV) is an arbovirus transmitted to humans by Tanzania . The worTanzania . Since iTanzania .Human CHIKV infection is characterised by an intense joint pain of abrupt onset, high fever, and rash. The infection is self-limited and acute symptoms usually resolve within one–two weeks. However, this polyarthralgia is recurrent in 30–40% of infected individuals and may persist for years . The joiThe first case of autochthonous CHIKV transmission in Brazil was reported in September 2014, in the state of Amapá (AP). That same month, an outbreak caused by a different genotype occurred in the city of Feira de Santana, state of Bahia (BA) . From thThe present review aims to present the current state of CHIKV infection in Brazil and highlight its clinical aspects and treatment. Some of the information described in this article comes from experience acquired in the field, during a research project that is under development in Feira de Santana, which has been following a cohort of individuals infected with the CHIKV for 18 months.CHIKV – CHIKV is a member of the Togaviridae family, genus Alphavirus, and belongs to the Semliki Forest antigenic complex. Among the members of this antigenic complex are Mayaro, O’Nyong-nyong and Ross River viruses, all of which are capable of causing disease in humans (n humans .Chikungunya is a positive-sense single-stranded RNA virus that is approximately 12 kb in length. The genome has two open reading frames (ORFs): the 5´ORF, translated from genomic RNA, encodes the nsP1, nsP2, nsP3, and nsP4 non-structural proteins, and the 3´ORF, translated from subgenomic RNA, encodes a polyprotein that is processed into the structural proteins  .The viral particle is spherical, approximately 70 nm in diameter, formed by 240 copies of the capsid protein and surrounded by an envelope composed of a lipid bilayer. Inserted in the envelope are 80 trimer-shaped spikes formed by E1 and E2 glycoproteins .Distinct CHIKV genotypes have been identified and comprise the East, Central and South African isolates [East–Central–South–African (ECSA)], West Africa isolates (West Africa), and Asian isolates (Asian). The Indian Ocean lineage (IOL) was identified in 2004 as a descendant of the ECSA lineage .Viral replication – Different cells are able to sustain CHIKV infection, including epithelial cells, endothelial cells, primary fibroblasts and monocyte-derived macrophages. CHIKV enters the target cell through receptor-mediated endocytosis. To date, no cellular receptors have been identified. After endosome formation, changes in pH promote conformational changes in the envelope proteins that lead to the fusion of the viral membrane with the endosomal membrane. During this phase, the nucleocapsid is released into the cytoplasm. Viral RNA released into the cytoplasm is translated to form the four proteins of the viral replication complex (nsP1–nsP4), which mediates the synthesis of a negative RNA intermediate that serves as a template for the synthesis of the subgenomic and genomic RNA. Subgenomic RNA is translated into the structural proteins of the capsid, pE2 (precursor of E2 and E3), E1, and 6K. In the cytoplasm, the capsid proteins associate to form the nucleocapsid, which incorporates genomic RNA during the maturation process. The envelope precursor proteins are transported to the endoplasmic reticulum and Golgi complex where they undergo post-transductional modifications to form the E1–E2 heterodimer. These proteins are transported to the host cell membrane to form viral envelope spikes. The virus is then freed from the host cell through the budding process  occurred in Feira de Santana . By the Brazil is experiencing a triple epidemic caused by the dengue, CHIK and Zika viruses. Brazil is a country of continental dimensions, with a population density of 24.2 inhabitants/km2, and a human development index (HDI) of 0.68 . The preAedes spp, particularly Aedes aegypti, which is one of the most efficient mosquito vectors for arboviruses. This efficiency is mainly because this genus is highly anthropophilic and lives in close proximity to humans  allowed the virus to better adapt to the vector, thus increasing its ability to transmit and disseminate the virus. This finding was observed in the strain of CHIKV that circulated during an outbreak in the Indian Ocean islands, referred to as the Indian Ocean lineage  or IgM results, 678 had been exposed to the virus. Of these, 39 exhibited viraemia in the intrapartum period and approximately 49% of their newborns were infected .The transmission of arboviruses through the blood of patients in the viraemic period may cause a major problem for blood donation in endemic areas. During the epidemic in La Reunion, the French blood service (Etablissement Français du Sang) interrupted blood donations on the island. At the time, an estimated 47 of the 37,750 blood bags donated during the epidemic may have been contaminated if the donations had not been interrupted . In a stClinical spectrum of CHIKV infection – After the mosquito bite, the virus enters the skin and the bloodstream. Following the initial replication within dermal fibroblasts, the virus spreads through the bloodstream to the liver, muscles, joints, spleen, lymph nodes, and brain. During the first week of infection, the viral load reaches 109 copies/mL of blood. The viraemic period in the vertebrate host may last two–10 days after infection , a lack of rest during the first days of the disease, and the prior existence of musculoskeletal comorbidities contribute to the persistence of the clinical condition .Several studies have described the main clinical manifestations observed during the post-acute phase, which represent the persistence of the initial inflammatory process, including articular and periarticular involvement, whose main clinical manifestations are arthralgia, arthritis (synovitis with or without effusion), tenosynovitis, bursitis, enthesitis, periostitis, and tendinitis, with the risk of tendon rupture. This process may occur in two ways: (i) continuously, with signs and symptoms occurring uninterruptedly, or (ii) with recurrent attacks of intermittent polyarthralgia or polyarthritis, often aggravated by cold . E in fiDuring the post-acute phase, the decompensation of pre-existing traumatic or degenerative arthropathies, such as osteoarthritis or tendinitis, occasionally calcified, may occur. Additionally, local manifestations, such as reactional oedema and nerve compression syndromes, particularly of the ulnar, medial, and tibial nerves, which produce cubital, carpal, and tarsal tunnel syndromes, respectively, have also been observed. Morning joint stiffness, neuropathic pain, and peripheral vascular phenomena, such as Raynaud syndrome, have also been described .Notably, during this phase, a set of non-specific clinical manifestations that are not always associated with chikungunya usually occurs, which may be overlooked by health professionals. The most frequently reported manifestations are chronic fatigue, changes in skin colour (hypo- or hyperchromia), alopecia, decompensated endocrine and metabolic diseases, and decompensation of other pre-existing chronic diseases, such as systemic arterial hypertension, depression, and anxiety . During Chronic phase – The disease is considered chronic when the arthralgia persists for more than three months. The percentage of patients who progress to the chronic phase varies from 40–80%  and theySignificant differences in the spectrum of clinical manifestations and in their intensity and frequency may occur during this phase. As in the acute phase, during the chronic disease, arthralgia and arthritis tend to be bilateral and symmetrical and may be migratory, with pain assuming an intermittent or constant characteristic, possibly accompanied by articular oedema or morning joint stiffness. When oedema occurs, redness and heat are usually not present.According to a prospective study performed in India with approximately 200 patients, the most frequently observed signs and symptoms during the 10th month of follow-up were joint pain in 46% of patients, fatigue in 13%, and tingling and numbness in the extremities, suggestive of neuritis, in 6%. A subgroup of these patients underwent magnetic resonance imaging exams, which showed joint effusion, bone erosion, bone marrow oedema, synovial thickening, tendinitis, and tenosynovitis .Among individuals in the chronic phase and regarding the disease progression, three different groups have usually been observed: (i) a larger group in which the disease progresses to cure, spontaneously or after treatment, without lasting sequelae; (ii) a group that is affected by a prolonged persistence of general clinical and/or joint manifestations; and (iii) a group in which the disease tends to become more serious due to the exacerbation of the degenerative or inflammatory process .Some studies have revealed that in 80–100% of patients, joint involvement tends to persist for at least six weeks and that, over time, this percentage would decrease to approximately 10% at the end of the second or third year after the acute phase .Other types of musculoskeletal manifestations may characterise the chronic phase, with the most frequent being tenosynovitis. Typically, two or more tendons are affected, the most common of which are the wrist, finger, and ankle extensors and flexors. Many patients with hypertrophic wrist tenosynovitis complain of nocturnal paraesthesia in the fingers. As in the post-acute phase, cubital, carpal, and tarsal tunnel syndromes have also been described. These syndromes are usually bilateral and accompanied by hypertrophic tenosynovitis . B in fiThe negative impact of CHIKV infection on the patients’ health-related quality of life is quite severe and not limited to the acute disease. Moreover, it may last for several months after clinical recovery .Although CHIKV infection is usually benign, increasingly frequent reports have associated chikungunya with decompensation of several pre-existing diseases and an unexpected number of deaths. During the Caribbean and Americas epidemics, between 2013 and 2014, 65 patients were admitted to an intensive care unit with CHIKV infection. Among them, 54 (83%) had pre-existing diseases and 27 were admitted due to an exacerbation of a comorbidity . BetweenLaboratory diagnosis – Infections by other Arbovirus in areas that are endemic for dengue are usually incorrectly diagnosed when based solely on clinical and epidemiological data. Many cases of acute febrile diseases have been misdiagnosed and the circulation of other disease-causing arboviruses may be much greater than reported.The laboratory diagnosis of CHIKV infection is based on viral isolation, viral RNA identification through molecular techniques, such as reverse transcription (RT) and real-time PCR and the detection of IgM and IgG antibodies through serological tests using enzyme linked immunosorbent assays (ELISA) and/or rapid immunochromatographic tests . The choViral isolation must be performed using samples collected on or before approximately the eighth day of infection. CHIKV produces cytopathic effect in approximately three days when inoculated in a variety of cell types. The main cell lines used are Vero, BHK-21, and HeLa. The confirmation of CHIKV isolation may be through immunofluorescence or RT-PCR. Although viral isolation is a highly specific method, the time required to obtain results is long. Moreover, a biosafety level 3 (BSL-3) laboratory is required .Although techniques based on RT-PCR provide a rapid and sensitive diagnosis, they only permit the detection of viral nucleic acid on or before the seventh day after symptom onset. Regardless, this method is an important tool for the early diagnosis of this infection, particularly in cases of meningoencephalitis and vesiculobullous dermatitis in newborns, for example, in which early diagnosis is essential for successful treatment .Available serological tests include ELISA and point-of-care (POC) immunochromatographic tests, which allow IgM detection from the fifth day after symptom onset and IgG detection only a few days later . The advNotably, cross-reactions with other members of the antigenic complex Semliki Forest, including Mayaro virus  have beePharmacological treatment of pain during the acute phase – The following recommendations were based on a protocol developed by a multiprofessional group for the treatment of pain in chikungunya . The refBefore beginning treatment during this phase, the physician should heed certain precautions to prevent undesirable reactions:Ask the patient about any history of allergies or adverse reactions to the medication that will be used .Investigate the existence of any comorbidity that may cause adverse reactions to the medication used during this treatment stage, such as diabetes, arterial hypertension, glaucoma, renal insufficiency, and cardiomyopathies.Remember that CHIKV infection may cause decompensation of pre-existing diseases.Avoid imprecise prescriptions, such as “as needed”.Avoid non-steroidal anti-inflammatory drugs (NSAIDs) during this phase.Avoid corticosteroids during this phase, except for specific manifestations, such as neuritis or encephalopathy.Recall that hydration and absolute rest are crucial components of the integrative approach to the patient.Address special attention to monitoring the risk of toxicity due to medication, whether due to overdosage, prolonged use, or self-medication.Mild-intensity pain (VAS from 1 to 3) – The two most commonly used analgesics are dipyrone and paracetamol, which offer quite satisfactory results when they are correctly prescribed. For an adult individual weighing more than 60 kg, dipyrone is recommended at a dosage of 1.0 g every 6 h. Paracetamol may be prescribed at dosages of 500–750 mg every 4–6 h, not exceeding the maximum daily dosage of 4.0 g due to the risk of hepatotoxicity.Moderate-intensity pain (VAS from 4 to 6) – For pain defined as moderate-intensity, i.e., VAS between 4 and 6, dipyrone and paracetamol should be prescribed together in the same fixed dosages (6/6 h), alternating their administration every 3 h, thereby providing the patient with an analgesic dose of a different product every 3 h.In cases of allergy to dipyrone, tramadol hydrochloride should be used. However, the use of these two drugs must be considered carefully in pregnant or breastfeeding patients.When moderate pain does not subside with the use of dipyrone with paracetamol, the 4–Question Neuropathic Pain Diagnostic Questionnaire (DN4) should be applied .For patients with severe neuropathic pain, 25 or 50 mg of amitriptyline hydrochloride may be combined with the analgesic being used (dipyrone or paracetamol). Two other medications may also supplement the analgesic: 300 mg of gabapentin twice a day , with a maximum dosage of 1,200 mg/day or 75 mg of pregabalin twice a day as the starting dose, which may be increased to a maximum dosage of 600 mg/day (300 mg twice a day).Strict precautions must be followed regarding the use of antidepressants and anticonvulsants. For example, the use of amitriptyline should be avoided in older adults, for whom gabapentin is recommended and must be prescribed in progressive doses. Additionally, the use of amitriptyline is not recommended for patients with either a past or existent history of cardiac arrhythmia.Severe-intensity pain (VAS from 7 to 10) – To alleviate severe-intensity pain, dipyrone or paracetamol should be combined with an opioid. Opioids may cause nausea and constipation, which may be alleviated easily with the use of routine antiemetics and laxatives.Among the most frequently used opioid drugs are tramadol hydrochloride, which is typically prescribed at a dosage of 50–100 mg orally every 6 h and 30 mg of codeine combined with paracetamol (500 mg) every 6 h.Should the pain persist at the same intensity after one week of using an analgesic with an opioid, the DN4 questionnaire must be applied. If confirmed the neuropathic pain one of the previously described options for moderate-intensity pain, with the same characteristic (neuropathic pain), should be used.If the DN4 questionnaire results exclude the existence of neuropathic pain, the use of corticosteroids or NSAIDs should be considered because, at this point, the disease will have already progressed for two to three weeks. The medications and respective dosages are the same as described for pain in the post-acute phase.All precautions regarding the use of opioids and corticosteroids must be followed and the exclusion criteria for these classes of drugs must be investigated thoroughly because the prevalence of conditions such as diabetes, hypertensions, glaucoma, and severe cardiomyopathies is quite high among the general population in Brazil.Pregnant women – Paracetamol is the first option to relieve the pain caused by chikungunya in pregnant women and the dose should not exceed 4 g/day. From the 24th week of gestation onwards, all NSAIDs  are contraindicated due to the risks of foetal renal failure and closure of the ductus arteriosus. Performing a caesarean section to prevent the transmission of CHIKV to the newborn has not been recommended. Conversely, although measures aimed at delaying delivery beyond the viraemic phase have been attempted, positive results have not been consistently achieved .Newborns and children – Newborns whose mothers had confirmed viraemia in the period immediately before birth should be placed under neonatal monitoring for five days at the same birthing facility .Children with classic chikungunya disease are treated symptomatically as adults, avoiding NSAIDs in infants younger than three months of age or before 10 days of disease progression. Codeine is not recommended for children under 12 years of age and should be reserved for cases refractory to paracetamol.Treatment of pain in the post-acute phase – The post-acute phase is considered the period between the 22nd day after the onset of disease and the end of the third month. As described, the percentage of patients with sustained clinical manifestations beyond the first three weeks is variable. Prescribing medications for patients in this phase is aimed at relieving joint pain, which is usually a consequence of joint and periarticular inflammatory processes, and therefore, pain relief is conditional on the resolution of the inflammation.The presence of a neuropathic component to the pain should remain under investigation using the DN4 questionnaire and, if present, the use of antidepressants or anticonvulsants should be recommended. Because the persistence of inflammation and pain magnifies patient suffering, psychological support is essential, and the use of antidepressants, irrespective of neuropathic pain is indispensable.Mild-intensity pain (VAS from 1 to 3) – For mild-intensity joint pain, i.e., scoring between 1 and 3 by the VAS, NSAIDs are the first therapeutic option. Because many options exist within this drug class, agent selection is often based on the existence of contraindications, which are almost always associated with comorbidities or age. Examples of agents that may be used for the described pain are ibuprofen at a dosage of 400 mg every 8 h, nimesulide (100 mg/day), or meloxicam (7.5–15 mg/day). Satisfactory results have also been obtained with the use of naproxen at 500–750 mg/day. NSAIDs may be used for seven to 10 days, when its use should be reassessed.When the pain subsides, the medication should be suspended; conversely, should pain complaints persist, corticosteroids should be prescribed at an anti-inflammatory dose. More frequently, prednisone has been used at a dosage of up to 0.5 mg/kg body weight/day, not exceeding 40 mg/day in a single daily dose, administered in the morning. The symptoms usually subside over an average period of approximately three weeks. Should the symptoms subside, the same dosage should be maintained for another three–five days, after which a gradual reduction should be initiated (“weaning”), decreasing by 5 mg every seven days.Cautions regarding NSAIDs:Before initiating treatment with an NSAID, any existing comorbidities that may contraindicate its use must be carefully investigated.In older adults, an evaluation of urea, creatinine, and transaminase levels is recommended before, during, and after NSAID use.Some comorbidities that contraindicate the use of NSAIDs, when they are decompensated, are very frequent in the adult population .The need to prescribe a gastric protector must always be evaluated.Moderate- or severe-intensity pain (VAS from 4 to 6 and from 7 to 10) – For moderate- or severe-intensity pain, the first choice is usually corticosteroid therapy. Unless absolute contraindications exist regarding their use, NSAIDs should be used and, if required, given with an opioid, such as tramadol, in the aforementioned doses. Prednisone remains the corticosteroid of choice, at the previously described dose. Conversely, caution is necessary regarding the clinical reassessment of the patient and the appropriate time to initiate the “weaning” process.A proportion of patients with moderate- or severe-intensity arthralgia usually exhibits recrudescence of the pain condition or perhaps recurrences after short periods of pain relief. When this occurs, the corticosteroid should be reintroduced at the full dose that was previously used. This dose should be maintained for another three or five days after complete symptom resolution and the “weaning” should proceed more gradually, such as by 2.5 mg per week.For a localised inflammatory process, such as an isolated case of tenosynovitis, bursitis, capsulitis, a tunnel syndrome, or synovitis, which may not respond adequately to oral medication, the recommendation is to use a topical anti-inflammatory or to administer an injection with corticosteroids to the affected region, if necessary. In addition, surgical decompression to relieve recurrent pain from a tunnel syndrome is not recommended due to the risk of poor healing and algodystrophy .Pharmacological treatment in the chronic phase – The persistence of clinical manifestations for more than three months from the onset of symptoms is considered a chronic phase. The arthralgia is mild in some of these patients, signifying that the disease is in true regression; in such cases, the joint inflammation is minimal and resolves in a few additional weeks. In contrast, in an appreciable percentage of patients, intense inflammatory manifestations are observed, many of which adequately fulfil the criteria of the American College of Rheumatology to be classified as rheumatoid arthritis.For mild- to moderate-intensity pain, according to the VAS complemented by the physical examination, the therapeutic recommendations are identical to those previously described. For cases in which the pain intensity is evaluated as strong (VAS from 7 to 10) or for those whose moderate (VAS from 4 to 6), pain is not responding satisfactorily to the therapeutic regimens in use, other drugs must be used. Among these options are the so-called disease-modifying antirheumatic drugs (DMARDS), with methotrexate and hydroxychloroquine. Due to their potential for causing other systemic effects and adverse reactions, these products should be prescribed only by trained professionals; for this reason, their use is not detailed in the current review.Other approaches to relieving pain and inflammation – Several other interventions can and should be encouraged as additional measures to reduce joint involvement, which contribute to improving patient quality of life.During the acute phase, rest should be one of the main recommendations. Physical activities tends to aggravate the joint inflammatory process, contributing to local wear and thus to prolonging the clinical condition. Therefore, the need to provide a medical certificate that allows the patient a work exemption during the acute phase should always be evaluated. In the chronic phase, adaptation to another activity that does not require as much effort from the involved joints may often be necessary.Certain physical and local measures should be encouraged, including (i) the placement of a patch containing an NSAID gel; (ii) joint puncture to drain fluids or to inject corticosteroids; (iii) the (short-duration) use of an orthotic to rest the inflamed joint; and (iv) active and passive movement, which is always made gently to avoid causing pain .Antiviral drugs – Several drugs have a recognised effect against CHIKV, when tested in vitro, including ribavirin, interferon alpha, chloroquine, arbidol, favipiravir, and furin inhibitors. However, there is no specific antiviral treatment against the infection .Vaccine – The first attempts to develop inactivated and attenuated vaccines against CHIKV resulted in products with low immunogenicity and adverse effects such as arthralgia . AlthougAe. aegypti infestation that exist in Brazil. For these reasons, it is urgent to organise a multidisciplinary patient care network, in which primary care units will play the leading role.As described herein, chikungunya is a disease recently introduced in Brazil, which remains unfamiliar to a significant portion of the population and to health professionals. Its clinical management is complex and often requires laboratory support for diagnostic confirmation of its aetiology, which is not available on a large scale. Conversely, the high temperatures and abundant rainfall, in addition to severe deficiencies in the collection of solid urban waste and an irregular water supply for domestic use, are factors that contribute to the high levels of Photographs – Included in this article are photographs of patients at different stages of the disease. All patients had laboratory confirmation of CHIKV infection. The Chikungunya in the municipality of Feira de Santana (Bahia), Brazil: clinical, epidemiological, laboratorial, and quality of life studies, has been approved by the Ethical Committee from the Feira de Santana State University .


Epiduroscopic laser neural decompression (ELND) is one of the more invasive techniques for managing patients with herniated lumbar disc. However, ELND can be used to treat, and diagnose the epidural pathology; indications for ELND remain controversial, especially, when applied in cases of large disc extrusion and migrated disc. This paper reports cases of patients that were satisfied with the ELND procedure for migrated lumbar disc herniation.We reviewed the medical records of patients that received ELND for migrated lumbar disc in an outpatient clinic. The patients complained of low back pain with radicular pain with an intensity over 5 on a numeric rating scale (NRS) that had persisted for over 1 month. The Magnetic resonance imaging (MRIs) showed migrated lumbar disc herniation, and patients opted for ELND because they had previously experienced nerve blocks, and did not want to receive open surgery for their pain, even after the limitations of ELND were explained.Patients reported that their pain was dramatically reduced, and other discomfort symptoms, such as numbness, were also reduced after the procedure. In follow-up, all of the patients were satisfied with the results.We applied the ENLD procedure to mechanically, remove disc material that compressed the spinal nerve, and the patients were satisfied, and reported symptom relief. ELND was a sufficient treatment approach for lumbar migrated herniated disc for patients who did not want to undergo open spine surgery. Epiduroscopy has been applied for failed back surgery syndrome (FBSS), and application fields have extended as devices, and techniques have developed. Although a herniated lumbar disc is an indication of ELND, indications for ELND remain controversial, especially in cases of large disc extrusion, and migrated disc. It can be difficult, and challenging to choose the right method to treat patients with large disc extrusion, and migrated disc.Low back pain with or without leg pain is a major health issue for many patients that visit the outpatient pain clinic. Although there are many conventional options to manage this type of pain in patients, surgery was considered to be essential to treat lumbar herniated disc when conservative treatments failed. However, many minimally invasive techniques have been developed to treat patients with low back pain with or without leg pain who do not want to undergo open surgery. Epiduroscopic laser neural decompression (ELND) is a representative procedure that can treat patients with low back pain with or without leg pain under direct vision.We report very interesting cases where ELND was associated with good outcomes for patients with migrated lumbar disc who did not want to undergo open surgery, even when the limitations of ELND were explained.2This case series is based on retrospective design. Authors reviewed medical records of patients who received ELND for their low back pain with radiating leg pain from migrated disc herniation between March 2013 to 2017 in a single center which is a university hospital located in KoreaFour patients were enrolled, and their demographic data, Magnetic resonance imaging (MRI) findings of migrated disc, dose of laser used during the procedure, procedure time, pain score before and after the procedure were collected. This case series was approved by the institutional review board (IRB) of Daejeon St. Mary's Hospital (DC17RESI0071).2.1Four patients with low back pain who suffered from radiating pain rated at over 5 on the numeric rating scale (NRS) and had persisted for over 1 month visited our pain center for further interventional treatment. All patients had received conventional treatments including physical therapy, pharmacotherapy, and nerve blocks at local pain clinics. The demographic data are presented in Table 2.2ELND was performed in a clean operating room after the patient provided informed consent. All procedures were performed by one expert who had experienced more than 100 cases of ELND. The patient was placed in a prone position with a pillow under the pelvis, which allowed the legs to be spread wide. After sterilization, local anesthetics were allowed to infiltrate around the sacral hiatus. Using the Seldinger technique, a cannula was inserted into the caudal epidural space, and a catheter that contained the epiduroscope , and laser fiber  was then administered into the epidural space via the cannula. The catheter was administrated up to the level of the migrated disc in the anterior epidural space. After observing that the disc material blocked the advance of the catheter by the epiduroscope Fig. . The cat3Patients’ migrated lumbar disc shown in MRI was confirmed by epiduroscope, and partially removed by laser during the procedure. We recorded the amount of laser that was used, in addition to the total procedure time; however, these values were not found to be correlated with the size of the migrated disc. NRS of all patients was dramatically reduced just after the procedure Fig. . Further4We report 4 cases that treated migrated lumbar disc herniation by ELND. Miraged disc material was shown directly by epiduroscope, and removed by laser for decompression of spinal nerves. Final results were good in all cases. A prospective study recently focused on predicting post-epiduroscope treatment outcomes based on epiduroscoic findings. This approach allows low back pain with or without leg pain to be treated more actively without surgery.The epiduroscope was first introduced in the year 1931, and has developed rapidly in recent years. It is currently, a useful tool for diagnosing low back pain and is used to treat lesions in the epidural space by applying the laser as a minimally invasive intervention. Multiple factors can lead to FBSS, including degenerative change of the lumbar spine after surgery, epidural adhesions, and altered biomechanics after surgery. These changes can increase tension on prevertebral and postvertebral muscles. FBSS is usually refractory to any treatment and is challenging for many pain physicians.A lumbar herniated disc is a common disorder that elicits low back pain with or without radiating leg pain. Conventionally, there are 2 options for treating lumbar herniated disc: conservative treatments or surgery. Conservative treatment includes medication, nerve block , or physical therapy. The advantage of this approach is that it allows the patient to continue daily activity with less burden on both the patient, and physician, but its effectiveness is limited in some cases. Surgery has been considered the next step when conservative treatment fails to sufficiently relieve the patient's symptoms, but there are associated risks such as FBSS, and those from general anesthesia. The FBSS is defined as lumbar spinal pain of unknown origin after spine surgery, and is estimated to occur in 20 – 40% of those who receive lumbar spinal surgery.Minimally, invasive interventional techniques have recently, been used by pain physicians to avoid complications from spine surgery for treating low back pain. ELND is a representative minimally invasive intervention approach. ELND allows physicians to visualize the epidural space directly, and to remove pathologies with direct vision, without surgery in the epidural space. The ability to immediately, remove pathologies under direct vision is very valuable; because it overcomes the limitation of conventional conservative treatments. Compared to surgery, it is advantageous because normal body structures can be conserved, and the process can be repeated if it fails. Because ELND can be performed without general anesthesia, unintended nerve injury can be prevented by observing the patient's response during the procedure, and risks from general anesthesia can be avoided. ELND also has diagnostic value because, as the name ‘epidurosope’ implies, it allows for direct visualization of conditions in the epidural space such as disc fragments; epidural vessel dilatations; adhesion; and inflammation on the dura, nerve root, and annulus. Epidural adhesions, dilated epidural vessels, and inflammation can cause back pain, which is not visible on MRI. By observing the lesion findings directly by epiduroscope, the exact cause of the pain can be determined, and the appropriate treatment plan can be developed. We previously, reported a case in which ELND was used to identify, and treat a real pathology, which was not found on MRI. Despite these advantages, there is limited evidence for the applications of ELND, and there are a limited number of reports on the subject. ELND could be indicated for various conditions with low back pain; however, additional clinical trials, and case reports are needed to obtain procedural evidence, which will help determine the indications.As the device and technique have developed, the epiduroscope has become more useful for a wider variety of low back pain conditions. Especially, when using with laser, ELND can remove epidural pathologies under direct vision without surgery. Our report indicates that ELND was associated with good results for patients with chronic refractory low back, and/or lower extremity pain that could not be resolved by other conservative treatments.; however, no case reports have discussed patients with migrated disc herniation that have been treated only by ELND. This report summarizes 4 cases in which migrated disc herniation was treated using only ELND. Even after the limitations of ELND were discussed, and patients were advised to undergo open surgery, the patients elected to receive ELND instead of open surgery, and they were satisfied with the results.One case report indicated that a combination of percutaneous endoscopic lumbar discectomy (PELD), and ELND could be applied for down-migrated disc herniation When a consensus on the ending point is obtained, the limitations of the procedure should be accepted, such as the possibility of not completely, removing the pathologies from the epidural space due to very tiny instruments in a narrow space. Lasering is usually, performed until the dura is a downward move from the epiduroscopic view, and is movable, and based on the saline infusion at the upper part of the scope, which indicates spinal nerve decompression. At this point, the catheter can pass above the level of pathology, indicating sufficient space in the epidural area.There is currently, no consensus on the conclusion of an ELND procedure; therefore, it is difficult, and important to decide when the procedure should be completed. Excessive laser use can lead to unintended side effects.5In the cases in this report, we were able to mechanically, remove the disc material that compressed the spinal nerve through the ENLD procedure, and the patients’ symptoms were relieved with satisfaction. ELND provided sufficient treatment for lumbar migrated herniated disc for patients that did not want to undergo open spine surgery. However, the slow learning curve, and the high costs are currently barriers to the procedure. We hope that more cases of ELND will be reported, and we would like to determine appropriate indications of ELND based on the case reports.The authors have no funding to disclose for this paper and thank all the anonymous reviews and editors for their suggestions, which will be helpful for the authors to improve the paper.Conceptualization: D. Jo.Data curation: J. Oh.Writing – original draft: J. Oh.Writing – review & editing: D. Jo.