Lumbar central spinal stenosis (LCSS) is a common disorder that causes disability and pain in the elderly. It causes pain in the radicular leg. Recently, transforaminal epidural steroid injection (TFESI) has been widely used to control radicular leg pain caused by LCSS. However, in cases of severe LCSS, drugs injected using TFESI cannot spread into the spinal canal and would have less therapeutic effects than in mild LCSS. To compensate for this limitation of TFESI, we injected steroids and botulinum toxin type A into the bilateral facet joints, evaluated their effects, and compared them with those of TFESI. One hundred patients with severe LCSS were included in the study and randomly allocated to either the facet injection (FI) or TFESI group. For 50 patients in the FI group, 30 mg (40 mg/mL) of triamcinolone with 50 IU of botulinum toxin type A mixed with a 1 mL solution of 100 mL of 50% dextrose water and 30 mL of 4% lidocaine were administered into the bilateral facet joints under fluoroscopy. For 50 patients in the TFESI group, 30 mg (40 mg/mL) of triamcinolone with 0.8 mL of 2% lidocaine and 2.5 mL of 50% dextrose water was injected bilaterally under fluoroscopy. Radicular leg pain  and pain-related disability (measured with the modified Oswestry Disability Index) due to severe LCSS were significantly reduced after facet joint injection. The therapeutic effects were greater after facet joint injection than after bilateral TFESI. The injection of a mixed solution of steroids and botulinum toxin type A into the bilateral facet joints would be a beneficial therapeutic option in patients with severe LCSS. The prevalence of symptomatic lumbar central spinal stenosis (LCSS) is approximately 27% in the general population . LCSS isEpidural steroid injections are commonly administered to patients with LCSS ,7,8,9. IRecently, some previous studies reported that steroid injection into the bilateral facet joints had a better therapeutic effect in LCSS through the epidural spread of the injected drug from the facet joint space compared with that of interlaminar epidural steroid injection ,16. In aThe present study evaluated the effect of steroid and botulinum toxin type A injections into the bilateral facet joints in severe LCSS and compared their effects with that of bilateral TFESI. The main outcomes of our study were changes in leg pain and functional disability, which were measured by the numeric rating scale (NRS) and the modified Oswestry Disability Index (MODI), respectively.p > 0.05). In addition, there was no significant difference in the number of injections between the two groups  group = 2.3 ± 0.9; the mean number of injections in the TFESI group = 2.3 ± 0.6).None of the patients dropped out during the follow-up period. No adverse events were observed in the FI or TFESI groups. There were also no significant differences in demographic data between the FI and TFESI groups (p < 0.001) (p < 0.001). Reductions in NRS scores over time were significantly larger in the FI group than in the TFESI group (p < 0.001) (p < 0.001).Regarding the NRS changes after treatment, the mean NRS score in the FI group decreased after treatment. The pretreatment NRS was 5.7 ± 0.7. At 4, 8, and 12 weeks after injection, the mean NRS was 3.6 ± 0.8, 3.6 ± 0.9, and 3.7 ± 1.2, respectively . In the < 0.001) . In both< 0.001) . In addip < 0.001) (p < 0.001). The reduction in the ODI scores over time was significantly larger in the FI group than in the TFESI group (p < 0.001) (p < 0.001).Regarding the MODI changes after treatment, the mean MODI in the FI group decreased after treatment. The pretreatment MODI was 62.0 ± 6.1. At 4, 8, and 12 weeks after injection, the mean MODI was 45.7 ± 4.8, 44.3 ± 5.7, and 45.4 ± 7.5, respectively . In the < 0.001) . In both< 0.001) . In addiIn our study, we found that the injection of steroids and botulinum toxin type A into the bilateral facet joints had a positive therapeutic effect for controlling radicular leg pain and improving functional disability due to severe LCSS. This effect was greater than that of bilateral TFESI.Facet joint injection is usually performed to control facet-origin axial back pain . HoweverCompared with epidural steroid injection, facet joint injection has the advantage of being a safe and less invasive technique, because it does not directly puncture the epidural space or spinal radicular artery . In contBotulinum toxin type A is known to have analgesic effects ,18. It cIn patients with LCSS, mechanical compression or chemical irritation around the nerve root contributes to radicular leg pain . BilaterIn conclusion, we showed that radicular leg pain and pain-related disability due to severe LCSS were significantly reduced after the injection of a mixed solution of steroids and botulinum toxin type A into the bilateral facet joints. Furthermore, it had a better therapeutic effect than bilateral TFESI. We believe that the injection of steroids and botulinum toxin type A into the bilateral facet joints is a feasible therapeutic option in patients with severe LCSS. Our study had some limitations. First, a long-term follow-up was not conducted. Second, the effects of facet injection and TFESI were not compared with those of the placebo procedure. Third, our study included a relatively small number of participants. Fourth, the required sample size could not be calculated because there was no previous research that could be used as a reference for our study. Further studies addressing these limitations are warranted.This prospective study was conducted at a single outpatient pain clinic. We prospectively recruited 100 consecutive patients with lower leg pain due to LCSS according to the following inclusion criteria: (1) age between 20 and 79 years; (2) ≥3 months history of lower leg pain due to LCSS, characterized by bilateral or unilateral leg pain in a diffuse distribution during walking or prolonged standing with relief by sitting or leaning forward; (3) pain intensity of >5 on an NRS ; and (4) severe or extreme LCSS on T2-axial magnetic resonance imaging. LCSS severity was determined based on a previous study by Schizas et al. . In seveThe recruited patients were randomly allocated to two groups. Randomization was performed using a table of random numbers. The patients were allocated using sealed, opaque envelopes containing the randomization. Fifty patients were classified into the FI group, in which steroids and botulinum toxin type A were injected into the corresponding bilateral facet joints, and the other 50 patients were classified into the TFESI group, in which TFESI was conducted bilaterally on the corresponding level. Facet joint injection and TFESI were performed up to three times at intervals of 2 weeks until radicular leg pain was reduced by ≥60% of pain at pretreatment.The patients were placed prone, and the fluoroscopic tube  was angled cephalad and rotated until it was tangent to the lumbar facet joint space. Under the guidance of fluoroscopy, the tip of a 25-gauge, 90 mm spinal needle with a bend at the tip was positioned within the inferior facet recess of the targeted lumbar facet joint. After confirming intra-articular access by injecting 0.3 mL of contrast into the lumbar facet joint space , left, 3All the injections were performed by a single interventionist with 20 years of experience in pain intervention. A strict aseptic technique was applied to all the procedures. The patients were placed prone, and the fluoroscopic tube  was rotated obliquely to the ipsilateral oblique ankle with respect to the suspected nerve root. Under the guidance of fluoroscopy, the tip of a 25-gauge, 90 mm spinal needle with a bend at the tip was positioned between the lateral vertebral body and the 6 o’clock position below the pedicle. Lateral fluoroscopic imaging demonstrated a needle tip between the spinal laminar margin and posterior vertebral body. Under anteroposterior fluoroscopy, approximately 1 mL of non-ionic contrast material was injected to confirm the absence of vascular uptake and the spread of contrast into the foramen , right. The same investigator, who was blinded to the patients’ grouping and did not participate in the treatment, assessed the degree of leg pain due to LCSS using NRS and the functional disabilities using the MODI at pretreatment and all follow-up assessments. Follow-up assessments were conducted 4, 8, and 12 weeks after the first injection.t-test and chi-square test. The changes in NRS and MODI scores in the TFESI and FI groups were evaluated using repeated-measure 1-factor analysis. Repeated-measure 2-factor analysis was used to compare the changes between the groups over time. Multiple comparisons were obtained following a contrast under Bonferroni correction. Statistical significance was set at p < 0.05.Data were analyzed using the Statistical Package for Social Science . Demographic data and the number of injections were compared between the TFESI and FI groups using the independent


Regarding postoperative pain, it remains unclear whether non-fixation of thepolypropylene prosthesis in transabdominal preperitoneal inguinal herniarepair produces the same outcomes as mesh fixation with glue or tackers. Inaddition, hernia recurrence is another aspect to be assessed in thecomparison between non-fixation and mesh-fixation techniques (tackers andglue).This study aimed to evaluate the incidence, quality of pain, and recurrencein patients undergoing laparoscopic inguinal hernioplasty  technique, comparing the fixation of the mesh with tackersversus with glue versus without fixation.This is a prospective, double-blind study in which 63 patients presentingwith primary unilateral inguinal hernia underwent laparoscopictransabdominal preperitoneal inguinal hernia repair and were randomized intothree groups: no mesh fixation (n=21), mesh tacked (n=21), and mesh fixedwith fibrin glue (n=21). Patients also responded to questionnaires in orderto assess pain and pain quality and were followed up for 2 years.Neither mesh-fixation nor non-fixation techniques were found to affectpostoperative chronic pain (p=0.535), but patients undergoing tackerfixation reported more pain descriptors (p=0.0021) and a higher pain index(p=0.002) on the McGill scale in the first 15 postoperative days (T0 andT1). No hernia recurrences were observed.Both mesh-fixation techniques (tackers and glue) used with the transabdominalpreperitoneal approach did not influence the onset of inguinodynia, buttacker fixation was more likely to increase patient sensitivity to pain.Mesh placement without fixation produced the same pain and recurrenceoutcomes as mesh-fixation techniques. Also, no recurrence was observed inpatients without mesh fixation in this study. Consequently, it has become analternative therapy deserving consideration for hernia repair. It is estimated that approximately 20 million hernioplasties are performed worldwide and in Brazil in the year of 2019, 122.631 hernioplasties were performed in the public health system.Inguinal hernioplasty is among the most common types of procedures performed bygeneral surgeons.The use of meshes in the surgical treatment of inguinal hernias has led to decreasedrates of recurrence. Consequently, chronic pain, also known as inguinodynia, hasbecome the main postoperative complication. The major etiologies of chronic pain comprise hernia recurrence, neuropathiccauses , and non-neuropathic causes and laparoscopy technique that is totallyextraperitoneal (TEP), a mesh can be stapled or glued, or not fixated as long as thehernia defect does not exceed 3 cm in size.In this respect, videolaparoscopic hernioplasty offers several advantages, includinglower postoperative pain and faster return to usual activities. However, there is a higher number of studies demonstrating that meshfixation is not necessary in the TEP technique, while there are only a few studies on TAPP hernia repair without mesh fixation.Many studies have not shown differences in pain and recurrence outcomes between thesetwo techniques. In addition, further studies on both the quantity and quality ofpatient-reported pain are needed to establish the differences between tacked andglued meshes, if at all. In addition, hernia recurrence rates following TAPPprocedures without mesh fixation should be compared to mesh fixation with tackers orglue.Regarding postoperative pain, the question is whether non-fixation of thepolypropylene mesh in videolaparoscopic TAPP inguinal hernioplasty produces the sameoutcomes as mesh fixation with fibrin glue or tackersThe aim of this study was to evaluate the incidence, quality of pain, and recurrencein patients undergoing laparoscopic inguinal hernioplasty (TAPP) technique,comparing the fixation of the mesh with tackers versus with glue versus withoutfixation.http://www.ensaiosclinicos.gov.br/rg/RBR-6d7twh/).This study was approved by the Ethics and Research Committee of the TransplantHospital Dr. Euryclides de Jesus Zerbini CAAE .Only 63 patients were selected for this study. The remaining 62 were excluded becausethey did meet the inclusion criteria or have one of the following conditions:adults aged under 18 and older than 75 years;having bilateral inguinal, incarcerated, strangulated hernia, or undergoneprevious surgery in the inguinocrural region, the right iliac fossa andhypogastrium, or prostate surgery;chronic analgesic, corticosteroid, antidepressant, and anxiolytic users;those rated as ASA Classes III, IV, and V; orno consent to randomization.A total of 63 sequential patients presenting with primary unilateral inguinal herniaunderwent TAPP inguinal hernia repair and were operated in this same hospital. Theprocedure was performed by the same surgical team, and this trial method wasperformed in accordance with the relevant guidelines and regulations and an informedconsent was obtained from all patients after explaining the purpose of the study aswell as free consent to refuse.Patients were randomized into three groups of 21 individuals. At the time of surgery,a randomization application (Random®) was used to allocate them into three differentgroups as mesh-fixation groups: fibrin glue (21), tackers (21), or non-fixation(21).) of at least 15 cm by 12 cm was introduced and placed in the dissectedpreperitoneal space.After induction of anesthesia, patients were placed in the Trendelenburg positionand in contralateral rotation to the hernia site. Subsequently, with a Veressneedle pneumoperitoneum was created, an 11-mm trocar was placed in the umbilicalregion, and two 5-mm trocars were inserted into the lateral borders of therectus abdominis muscle. The parietal peritoneum was then opened, and the mainanatomical landmarks were identified  followed bydissection and reduction of the hernial sac and lipoma removal when necessary.In nerve topography, extraperitoneal fat was preserved in order to protect thenerves. Next, an anatomical review of both the entire myopectineal orifice andall anatomical landmarks and references was made. Subsequently, a heavyweightpolypropylene mesh , the mesh was fixated with instillation ofn-butyl-2-cyanoacrylate  tissue adhesive on thepectineal ligament, rectus abdominis muscle, and laterally of the inferiorepigastric vessels 3 cm above iliopubic tract. In tacker group (TG), tackerfixation of the mesh was performed using an Absorbatack® stapler onto the pectineal ligament, rectusabdominis muscle, and laterally of the inferior epigastric vessels 3 cm aboveiliopubic tract. The control was non-fixation group (NFG).After a mesh-fixation method, or no mesh fixation, was chosen, according to thegroup, the peritoneum was then sutured with 2–0 polyglactin, and COMesh was placed covering the pectineal ligament, the rectus abdominis muscle, andlaterally of the inferior epigastric vessels without fixation..With the purpose for quantifying and qualifying postoperative pain in the firstpostoperative day (T0), patients were evaluated through physical examination bya surgeon who had not participated in the surgery and did not know whether themesh had been fixated, or which fixation method had been used (no access tooperate notes). To this end, two questionnaires were responded to: onecontaining a multidimensional classification of pain with verbal, numeric, andface scales , and the other being the McGill painindex and pain quality questionnairePostoperative follow-up took place between Day 7 and Day 15 (T1), after 3 andbefore 6 months (T2), after 1 year (T3), after 1 year and 6 months (T4), andafter 2 years (T5) following the surgery. For this, a third surgeon who had notparticipated in the surgery or evaluated the patient in the first postoperativeperiod was chosen to evaluate patients through physical examination looking forrecurrence and any complication and with a questionnaire containing amultidimensional classification of pain using verbal, numeric, and face scales(VAS) and the McGill pain questionnaire. and the McGill pain questionnaire, including calculation of the number of pain descriptors (range 1–20) andof a pain index (range 1–78).Regarding the period of pain, inguinodynia was defined as persistent pain lastingover 3 months. Pain was stratified according to a multidimensional painclassification scale, comprising verbal, numeric, and face scales (VAS: absenceof pain=0 or presence of pain=1–10)To estimate the sample, the pain score was used as the main criterion. Atminimum, a sample of 21 patients per group  is required to detectdifferences in pain averages, assessed over seven time periods ,with an 88.9% power in the analysis of variances, with repeated measures (F-testwith Geisser-Greenhouse correction), at a significance level of 5%. For thispurpose, a sample size effect of 0.54 between groups, 1.86 for time, and a 0.50autoregressive correlation structure was accepted. Both Friedman and Wilcoxonsigned-rank tests were used to find out whether the treatments were effective.Also, Kruskal-Wallis and Mann-Whitney U tests, in addition to the chi-squaretest, were performed to calculate the difference, if at all, between the groups.A level of 0.05 (p<0.05) was defined for this study. In this statisticalanalysis, the following software programs were used: SPSS version 20, Minitab16, and Excel Office 2010.. One of them had an L1 hernia, 46 had L2, and 6 had L3 hernias. In addition,only two patients were classified as having M1 hernias, while eight had M2 hernias.No patient was found to have M3 hernias .Assessment of the McGill scaleThis finding was not observed at other follow-up times  and 5.The descriptor most described was in 33% pain like sharp followed by pain liketenderness in 15.6%. There was no affective descriptor of pain in McGill scale inany period.When the groups were compared in pairs at T0 (using Mann-Whitney U test), differenceswere found because pain descriptors were significantly higher in the TG than in theothers. Pain descriptors were also significantly higher in the FGG than the NFG onlyin T0  and 7.During the 2-year follow-up, no hernia recurrences were observed in any of the threegroups.. Bullen et al. conducted a meta-analysis and systematic review on this topic and reportedthat patients undergoing laparoscopic repair have a lower rate of both acute andchronic pain. In a publication by the Herniasurge Group, it was shown that videolaparoscopic inguinal hernioplasty is less likely toproduce chronic pain and, in addition, leads to faster return to usual activities. Andresen et al., who aimed at comparing tackers and fibrin glue as mesh-fixation methods,suggested that the mesh fixation did not correlate with the onset of chronic pain.However, patients in the FGG experienced a lower rate of pain in the firstpostoperative days. In order to avoid bias, the design of this study establishedthat the surgeon chosen for postoperative patient follow-up must not know themesh-fixation technique, or whether the mesh had been fixated. During follow-up, nostatistical difference was observed regarding the onset of chronic pain on VAS for aperiod of 24 months, regardless of the method used for mesh fixation, as shown inthe systematic review conducted by Lederhuber et al.. In an attempt to dissociate the direct relationship between tissue injuryand pain and that in any painful experience, sensitive, emotional, and cognitiveaspects can be a bias, the McGill scale was applied, which is one of the bestinstruments and the most used to characterize and discern the components affective,sensitive, and evaluative of pain. So, the patients were asked to point out, basedon a list of pain descriptors, the type and the pain quality experienced. It wasfound that the ones in the TG had chosen more descriptors and a higher pain index,calculated for a period up to 15 days postoperatively (T0 and T1). Based on ourresults, we concluded that mesh fixation with a penetrating method (tackers) maycause a greater sensation of discomfort than other atraumatic methods such as gluefixation or mesh placement without fixation. Our results also revealed that patientsin the FGG chose more pain descriptors and a higher pain index on the McGill scalethan those in the NFG.Inguinal hernia has a high prevalence in the population, affecting approximately 27%of men and 6% of women, and inguinal hernioplasty is one of the world’s most widelyperformed surgeries and reiterate that as far as pain is concerned, whether acute or chronic, thefactors leading to increased patient sensitivity and perception of pain include notonly direct nerve injury but also inflammatory reaction with acute healing aroundthe tacker or around the point where glue was applied.These results are in line with studies conducted by Reinpold et al.. In this group of patients, both the number of pain descriptors and theMcGill pain index were found to be lower than those observed in the other two groups (TG andFGG). Based on our results, we suggest that careful and accurate dissection,especially close to nerve trajectories, and observation of all the technical andanatomical aspects of the myopectineal orifice are essential steps to avoid the onset of chronic pain, with or without meshfixation.To provide an additional perspective on the onset of chronic postoperative pain, agroup of patients was included in this study, to whom the mesh was not fixated butrather only placed after the anatomical repairs on the myopectineal orifice ofFruchaud were identifiedDuring the 24-month follow-up with no patients lost, no hernia recurrence wasidentified in any of the three groups, including the NFG, although our study has alimited casuistic the results were similar to those presented in studies publishedrecently, and in line with the current trend toward no mesh fixation in TAPP repairof both indirect primary hernias (regardless of size) and direct hernias measuringup to 3 cm. And it is worth underlining that the recurrence in non-fixation TAPP maybe due to clamshelling and dislocation of the mesh, while in TAPP with fixation(glue or tackers) prevent mesh folding. It may be a crucial factor preventingrecurrences; thus, sufficient dissection of preperitoneal space is of utmostattention. and did not affect the onset of any pain symptoms.During this follow-up, 7.94% (n=5) developed seroma postoperatively and were alltreated conservatively, and their symptoms disappeared in up to 6 months (T2) aftersurgery. This result is consistent with the literature worldwideIn our study, the method chosen for mesh fixation in TAPP inguinal hernia repair,whether tacker or glue fixation, did not influence the onset of chronic pain.However, it was noted that tackers may increase a patient’s sensitivity to pain inthe inguinal region. Mesh placement without fixation led to the same pain andrecurrence outcomes as those found in mesh-fixation techniques. Consequently,non-fixation has become an alternative therapy worth considering. In this study, nocases of hernia recurrence were found during follow-up.


IntroductionBipartite patella affects about 2% of people. Most cases are asymptomatic; however, some develop anterior knee pain during a sporting activity or trauma. When conservative treatment fails, surgery can be considered. This study aims to report the outcomes of fragment excision with or without lateral release in adults with the symptomatic bipartite patella.MethodsThe study was approved by the College of Medicine IRB. A retrospective review was performed. Patients were excluded if aged < 18 or had prior knee surgery. Data collected included: age, gender, BMI, sports played, occupation, physical exam findings, Saupe classification, conservative and surgical treatment, advanced imaging used, duration of follow-up, Lysholm score and postoperative complications.ResultsEight patients were studied. The average age was 28.4 years and BMI was 31.5. Sporting activities included hunting, swimming, soccer, golfing and softball. Occupations included office job, laborer, manufacturing plant worker and truck driver. All patients complained of anterior knee pain exacerbated by sports or work. All patients failed >6 months of conservative treatment. Saupe classification included seven types III  and one type II . Surgical treatment included one open excision, six arthroscopic-assisted open excisions and one arthroscopic-assisted open excision with the lateral release. The duration of follow-up averaged 15 months. The average preoperative and postoperative Lysholm score was 75 and 93, respectively. One postoperative complication occurred.ConclusionsBipartite patella is an uncommon cause of anterior knee pain in adults. When pain persists despite conservative care, fragment excision of less than 12% of the whole patella with or without lateral release resulted in excellent outcomes in the majority of cases. Bipartite patella (BP) is an anatomical variation found in 2% of the general population . BP occuBP was first documented in 1883 by Wenzel Gruber in St. Petersburg, Russia, during the autopsy of a 21-year-old farmer who had a small piece of bone attached superolateral to the patella .In the majority of patients, BP is asymptomatic and often an incidental finding on radiographs; however, rarely, it can cause anterior patellofemoral knee pain and localized tenderness. Symptoms often start at adolescence during sporting activities. The majority of symptomatic BP can be successfully managed with conservative treatment including rest, stretching, brief immobilization, bracing, moderation of sporting activity, NSAIDs and physical therapy .Current surgical modalities include open or arthroscopic excision, lateral retinacular release and open reduction internal fixation (ORIF) . The purThe study was approved by the College of Medicine Institutional Review Board IRB#:00012885). A retrospective chart and radiograph review were performed on patients who underwent surgery for symptomatic BP refractory to conservative treatment from 2009 to 2019. Patients who were excluded included: < 18 years of age or prior history of knee surgery. Data extracted included age, sex, laterality, body mass index (BMI), sporting activity, occupation, physical exam findings, conservative treatment, Saupe classification . The average age was 28.4 years  and BMI was 31.5 . All patients complained of anterior knee pain exacerbated by sporting or work-related activities, especially with kneeling, twisting, squatting, jumping, or lifting heavy items. Sporting activities included hunting (two), swimming (one), soccer (one), golfing (one) and softball (one). The levels of sporting activity included seven recreational and one collegiate level. Occupations included manufacturing plant worker (two), truck driver (two), office job (one) and heavy-duty laborer (one). MOI included repetitive traction forces (three) and trauma (five), which were asymptomatic prior to the injury. On the physical exam, six had tenderness to palpation directly over the site of the bony division, five had mild effusion and one had crepitus at the patellofemoral joint. All knees demonstrated a full range of motion. All patients had failed >6 months of conservative treatment including PT, activity modification, stretching, bracing, steroid injections, Kinieseo taping, icing and NSAIDs . Compared to the average preoperative Lysholm score of 75 , the average Lysholm Score at final follow-up was 93 . Postoperatively, six patients returned to pre-surgery sporting or occupational activity at an average of 4.7 weeks . Two patients received worker’s compensation. The most common postoperative finding was soft tissue swelling in five patients and 1 cm quadriceps muscle atrophy in four patients during the first-month follow-up visit. Thigh circumference was measured using a measuring tape and compared with that of the contralateral side. Two patients had chronic knee pain three years after surgery, one of whom applied for worker’s compensation.One complication occurred during the follow-up period in a patient treated by open excision. A 38-year-old manufacturing plant worker developed a postoperative wound infection and was treated with antibiotics; she applied for worker’s compensation and did not return to work. None of the workers compensation patients had a secondary procedure within five years.BP is a rare cause of anterior knee pain due to the failure of the secondary ossification centers of the patella to completely fuse during adolescence. BP occurs in 2% of the population with equal prevalence in males compared to females. BP is often an incidental, asymptomatic finding on radiographs . A direcThe majority of symptomatic BP can be successfully treated conservatively with activity modification, NSAIDs, icing, physical therapy, bracing or ultrasound-guided injections . When coOpen excision with resection of the accessory fragment is the most commonly performed procedure in adults ,13. LateWhen opting for excision with resection of the accessory fragment, it is important to consider the percentage of the patella that can be safely resected to minimize patellar instability, joint incongruity and arthritis . No moreOther operative modalities of symptomatic BP include arthroscopic excision, tension band wiring or ORIF ,20. In a2, respectively. Excision of the large fragments in these cases may have led to the incongruity of the patellofemoral joint and increased risk of arthritis [Tauber et al. reported an 18-year-old who suffered a traumatic separation from the synchondrosis while playing soccer. He was treated with tension band wiring of the atypical, large, and horizontal BP resulting in a successful bony union of the BP . Vaishyarthritis . ORIF wirthritis . In 2015rthritis .Limitations of this study include: 1) the small number of cases investigated due to the rarity of this pathological finding; 2) the lack of a control group and 3) the limited period of follow-up. Given the low prevalence of this condition in the normal population that is operated on, a randomized control was not possible.The current study reaffirms the existing literature. Open excision with or without lateral release followed by early patella, quadriceps, and patellar tendon mobilization serves as a viable surgical modality in treating adults with symptomatic BP. Excision of the accessory fragment, averaging approximately 7% of the overall patella, relieves pain and preserves the patellar integrity. Lateral release reduced the painful tracking forces applied to the synchondrosis. Postoperative outcome scores were good to excellent using the Lysholm scale at an average of 15 months’ follow-up. Complete return to sporting activity or work is patient-dependent and individualized according to the patient's discretion.Symptomatic BP is an uncommon cause of anterior knee pain in adults. Open excision with or without lateral release followed by early patella, quadriceps, and patellar tendon mobilization serves as a viable surgical modality in treating adults with symptomatic BP. When pain persists despite conservative care, excision of the accessory fragment of less than 12% of the overall patella relieves pain and preserves the patellar integrity. Lateral release reduced the painful tracking forces applied to the synchondrosis. Postoperative outcome scores were good to excellent with excellent pain relief and return to full sporting or occupational activity in the majority of cases.


Fibromyalgia syndrome (FMS) is a chronic widespread pain condition with mixed peripheral and central contributions. Patients display hypersensitivities to a spectrum of stimuli. Patients’ blunt pressure pain thresholds are typically reduced, and sometimes (∼15%) gentle brushstroke induces allodynia. However, aftersensations after these stimuli have not, to our knowledge, been reported.We examined the perception of blunt pressure and “pleasant touch” in FMS. Patients were first interviewed and completed standard psychometric questionnaires. We then measured their sensitivity to blunt pressure and perception of pleasant touch, including aftersensations; patients were followed up for 5 days to evaluate lingering pain from blunt pressure.We recruited 51 patients with FMS and 16 pain-free healthy controls (HCs) at a UK Pain Management Centre. Forty-four patients completed the aftersensation protocol. Most patients reported pain after the application of less mechanical pressure than the level of pressure at which HCs reported pain; median arm and leg thresholds for the patients with FMS were 167 kPa and 233 kPa, respectively. Eighty-four percent (31/37) of patients reported ongoing pain at the site of pressure application 1 day after testing, and 49% (18/37) still perceived pain at 5 days. Aftersensations after brushstroke were common in the FMS group, reported by 77% (34/44) of patients with FMS vs 25% (4/16) of HCs; 34% (15/44) of patients, but no HCs, perceived these aftersensations as uncomfortable. For patients with FMS who experienced aftersensations, brushstroke pleasantness ratings were reduced, and the skin was often an important site of pain.Pain after blunt pressure assessment typically lingers for several days. Aftersensations after brushstroke stimulation are a previously unreported FMS phenomenon. They are associated with tactile anhedonia and might identify a clinically distinct subgroup. Fibromyalgia syndrome (FMS) is a chronic widespread pain condition of uncertain etiology . FMS paistatic mechanical allodynia [, or dynamic mechanical allodynia, in 10–20% [, stimuli that would be painful in normal skin), patients with FMS, similar to patients with other chronic pain conditions, can report painful aftersensations (PAS), i.e., sensations that persist even though application of the stimulus has ceased [In patients with FMS, quantitative sensory testing (QST) , 12 demollodynia , but genn 10–20% . In relas ceased . In FMS,s ceased . After ns ceased .Anecdotally, other types of skin stimuli can also elicit painful aftersensations in patients with FMS; for example, in our practice, tender point testing required for the 1990 American College of Rheumatology  (ACR) diPatients participated in an ongoing phenotyping study aiming to correlate clinical with immunological phenotypes (ISRCTN: 18414398). They had been identified from a registry of patients assessed for treatment with an interdisciplinary pain management program (PMP) at a tertiary National Health Service hospital in northern England . All patients had consented for their names to be entered into this registry; the consenting rate for entry is 98%.2. Exclusion criteria included pregnancy or breastfeeding and inadequate understanding of the English language.Patients were approached for the phenotyping study by letter, and interested patients attended a single study visit. Inclusion criteria were FMS of more than 1 year’s duration, ACR diagnosis 2010  or 1990 With regard to aftersensations, drawing from clinical experience, we expected that patients would find both the clinical examination of tender points  and examUpon examination with brushstroke, as part of a protocol to assess pleasant touch, initial patients in this phenotyping study unexpectedly reported post-examination aftersensations, which often seemed unpleasant. These initial research subjects further advised that it was challenging for them to clearly identify aftersensations as “painful” and that the term “uncomfortable” would best encompass the unpleasant sensation that they experienced. We consequently adapted the study protocol to allow a more in-depth assessment of this phenomenon. We obtained ethics approval to inquire about the character of these sensations and to include a pain-free healthy control (HC) comparator group, which was subsequently recruited from university and health care staff.The phenotyping study received ethics approval from Health and Care Research Board Wales: 18/WA/0234. All participants gave written consent, and they were reimbursed expenses up to £30 for their travel and HCs an additional £30 for their time.After consent and confirmation of eligibility (see above), patients were asked questions pertaining to their general health and fibromyalgia symptomatology; this included the tissue location of their perceived most intense pains in “bones,” “skin,” “muscles,” or “joints,” with multiple answers permitted. Participants also self-completed a set of standardized questionnaires, which were then checked for completeness by a member of the team. These included the EQ-5D , the McGA brief mechanical QST protocol was designed to test patients’ mechanical pain threshold and skin sensitivity and was based on the protocol previously published by Boehme et al. . The pro“I will press this pressure measuring device against one of your muscles. Please immediately say NOW as soon as the usual sensation of pressure changes to an additional sensation which is painful such as‘burning,’‘stinging,’‘drilling’or‘aching’. This is not an endurance test, tell us as soon as this becomes painful. This will be carried out a total of 3 times.”Subjects were asked to sit comfortably, and a standardized script was read to them see . The scr2 rubber tip, which was placed on the skin. A continuous ramp of increasing intensity  was applied until the patient confirmed that the sensation of pressure had changed to an additional one of pain. The patient was not able to see the dial. The pressure pain threshold was determined as the arithmetic mean of three consecutive readings. The test sites were the lateral right arm over brachioradialis and the left leg over vastus lateralis.Static blunt pressure pain threshold was measured with a pressure algometer  with a 1-cmKeen to explore gentle touch in greater depth than can be achieved by formal QST, which measures only dynamic mechanical allodynia , we chosaftersensations. For testing protocols, please see After the protocol adaptation from participant eight onward (see above), subjects were additionally asked  about the presence of any brushstroke test sensations that occurred immediately after the cessation of the final stimulus, via a combination of yes/no, multiple-choice, and open-ended questions . First, t test with Welch’s correction for unequal variance was used. For non-normally distributed data, a Wilcoxon matched-pairs rank-sum test was used for paired data, and a Mann-Whitney test was used for unpaired data. For comparison of multiple non-normally distributed groups, a Kruskal-Wallis test was implemented. For categorical binary data, a Fisher’s exact test was used. For the non-normally distributed brushstroke tests and pressure pain threshold data, a Kruskal-Wallis test was used, with a Dunn’s post hoc test between groups with correction for multiple comparisons. A multiple linear regression model using a least-squares approach was used to analyze variability in brushstroke pleasantness, modeling for intercept and main effects only, and residual plots were assessed for assumption validity. Correlation was tested with a Pearson’s correlation coefficient, and again, residual plots were assessed. Odds ratios were calculated for the probability of experiencing aftersensations with FMS. Statistical significance was set at P < 0.05, and a correction for multiple comparisons was made for each hypothesis . All P values under 0.05 were displayed for completeness. We speculated that some aspects of the FIQR were particularly relevant in testing the hypothesis that aftersensations had clinical relevance, and therefore we analyzed several FIQR sub-items individually, which ranged from 0 (least impact) to 10   and analyzed with GraphPad Prism version 9 . Normality of data were tested with the Kolmogorov-Smirnov test. For normally distributed data, a paired or unpaired Student  impact) .Demographic data are displayed in U test. In this analysis, our data recapitulate the observation previously found (P < 0.01) [ < 0.01) . In our P value correction for multiple tests, only slow stroke intensity remained significantly reduced. Interestingly, the brushstroke pleasantness ratings were not affected  and fast stroke pleasantness (P < 0.0001) (r) was –0.3951 , and for the fast brushstroke, r was –0.4866 .We identified a fair degree of variability in the pleasantness ratings in the FMS group. To test for associations that might explain the loss of pleasant touch, we performed a multiple regression analysis with a model considering the degrees of pain-widespreadedness and somatic symptoms , psychological factors , and neuropathic symptoms as measured by PainDETECT, assuming a least-squares model. Only PainDETECT values  were significantly (inversely) associated with both slow stroke pleasantness ( 0.0001) . For sloP < 0.0005), and these aftersensations were never uncomfortable. The odds ratio of experiencing aftersensations with FMS was 10.2 . When only patients who experienced dynamic mechanical allodynia were considered, 83.3% (5/6) had aftersensations, and in 66.8% (4/6), these were uncomfortable.Patients reported lingering pain at the examination sites  with a frequency of 78.1% (25/31) at day 1 and 46.7% (14/30) at day 5. Brushstroke aftersensations were experienced by 77.3% (34/44) of subjects with FMS . In almoThe qualities of these aftersensations were similar in patients with FMS for both uncomfortable aftersensations (UAS) and non-uncomfortable aftersensations (nUAS), with “pins and needles” being the modal response, followed by a lingering sensation that the brushstroke was still taking place . The medWhen patients were stratified by whether they had undergone the PMP treatment, no trend was seen in the presence of brushstroke aftersensations. Of the 25 patients who attended the PMP, 76% (19/25) had aftersensations, and of the 19 who did not attend the PMP, 79% (15/19) had aftersensations.We compared demographics and FMS characteristics between patients with and without brushstroke aftersensations to examine whether this characteristic was associated with a particular clinical phenotype. We found that these groups did not differ in gender, age, FIQR, level of pain, Widespread Pain Index, Symptom Severity Score, pain catastrophizing, or EuroQual Visual Analog Scale .P < 0.05; Patients were asked about the perceived tissue location of their most intense pains , with multiple responses permitted. Eleven patients (of n = 44 who completed this question) recorded “skin” as the site of their most intense pain, and those with UAS reported “skin” more often  than did the nUAS  or nAS groups , pressure pain threshold testing, and brushstroke QST. Eighty percent (25/31) of patients had lingering pain on day 1 and 47% (14/30) on day 5 after examination. The existence of this phenomenon after blunt mechanical stimuli has previously been highlighted by others [In this study, we have investigated aftersensations persisting beyond the termination of mechanical stimuli applied to the skin of patients with FMS. We found that painful aftersensations (lingering pains) are frequently reported several days after study examination, which included application of blunt pressure during the ACR tender point examination  [To our knowledge, this is the first report of evoked paresthesia or aftersensations after skin-brushstroke testing in FMS. We found that such sensations are common compared with HCs and that patients, but not HCs, often perceive them as uncomfortable. Consistent with the literature, allodynia, defined as pain s (7/51) . This ph, reports of uncomfortable aftersensations, as opposed to non-uncomfortable or no aftersensations, after brushstroke were associated with reports of reduced pleasantness during brushstroke; on average, slow and fast brushstrokes were, in fact, perceived as unpleasant by this group. Experience of uncomfortable brushstroke aftersensations was not associated with blunt pressure sensitivity, however , as detected in our study, is consistent with recent reports by Boehme et al. [Reduced brushstroke pleasantness  brushstIntriguingly, patients who had attended our PMP treatment had reduced slow brushstroke intensity ratings. Brushstroke pleasantness ratings were not altered, however. These data might provide the first evidence of PMP treatment potentially affecting selected sensory characteristics in FMS. However, given that all patients in this study had been assessed for the suitability of PMP treatment, it is alternatively possible that the entrance criteria for our PMP also selected for patients with a distinct sensory phenotype. A prospective study in PMP participants would shed more light on these issues.Dynamic mechanical allodynia and dysesthesias are noted in several neuropathic pain conditions  , as wellThe PainDETECT questionnaire was validated as a tool to predict the relative contribution of neuropathic pain in neuropathic and nociceptive  conditions. Patients with fibromyalgia were excluded from the validation process, although PainDETECT has been increasingly used in this population. It has been proposed that fibromyalgia should not be considered a neuropathic pain state ; howeverThe German Research Network on Neuropathic Pain (DFNS)  has geneOur present study is limited, as it was not designed to interrogate aftersensations in detail, which were a surprise finding. We did not record their duration or examine whether their qualities were the same for both slow and fast brushstrokes. It should be noted that we did record a significant reduction in pleasantness between slow and fast brushstrokes in HCs and not in patients with FMS, which has been previously noted and underpins the C-fiber tactile theory, although it failed to meet significance in our study in all analyses. The control group was small and was restricted to females, and it did not, therefore, match the FMS group in this regard. Although the proportion of male patients with FMS included was small (n = 3), it is conceivable that aftersensations had some gender bias: In our FMS cohort, all males for whom we have data had aftersensations. The HC group also differed by age, body mass index, and weight, which were potential confounders.It is important to note that in the present study we measured both brushstroke QST and pressure algometry, and we performed tender point examination. It is not possible, therefore, to extract the relevant contributions of each of these in relation to persisting aftersensations (lingering pain). We further note that the pressure algometry, unlike the tender point examination, stopped exactly at the point of painfulness and involved two points on the body (the tender point examination involved 18 points). Therefore, we assume that the tender point examination was responsible for most of the lingering pain; however, this study was not designed to confirm this.We did not record data on the presence or absence of aftersensations in the HC group after pressure pain threshold detection, and this is a clear limitation. HCs have been reported to experience painful aftersensations after blunt pressure mechanical stimulus, though the frequency was low at 12% and of an unknown duration . PatientHere we report, for the first time, the presence of aftersensations after the cessation of an innocuous light touch stimulus in a cohort of patients with fibromyalgia. When present, these aftersensations are often uncomfortable. We also report on the prevalence of lingering pain after pressure examination. We suggest that these findings have key implications for clinicians examining patients and ramifications for experimental trajectories. The recognition of these aftersensations could reassure patients and inform the advice and education given to them. Further research is, of course, needed to investigate these phenomena in FMS and other chronic pains. In this regard, we note that medical efficacy is contingent on placing patients at the center of diagnostic formulations and the interrogation of etiologies.http://painmedicine.oxfordjournals.org.pnac089_Supplementary_DataClick here for additional data file.


Methadone is commonly considered an alternative opioid treatment for refractory cancer pain. This study aims to investigate the efficacy, safety, and cost of methadone in the treatment of refractory cancer pain.A retrospective study was conducted in patients who used methadone for refractory cancer pain from April 2016 to December 2020 at a cancer specialized hospital. Pain control, evaluated via pain score and breakthrough pain frequency, and adverse events of methadone were compared with analgesic regimens prior to methadone administration. The factors potentially affecting the switching outcome were analyzed via multivariate analysis. Moreover, the cost of pain control was estimated.Ninety patients received methadone for poor pain control (74.4%), intolerable adverse events (10.0%), or both (15.6%) after prior opioid treatments. Sixty-four patients (71.1%) were successfully switched to methadone with median pain score significantly decreased from 4.0 to 2.0 (p < 0.001) and median daily frequency of breakthrough pain from 3.0 to 0.0 (p < 0.001) at a maintained median conversion ratio of 6.3 [interquartile range (IQR): 4.0–10.0] to prior opioid treatment. Similar adverse event profiles of constipation, nausea, vomiting, and dizziness were observed between methadone and prior opioid regimens. The median daily cost of analgesic regimens was significantly reduced from $19.5 (IQR: 12.3–46.2) to $10.8 (IQR: 7.1–18.7) (p < 0.01) after switching to methadone. The 3-day switch method significantly improved the rate of successful switching compared with the stop and go method .Methadone is an effective, safe, and cost-saving treatment for patients with refractory cancer pain. Pain is one of the most common and unbearable symptoms experienced by cancer patients; it seriously impairs their quality of life , 2. ApprMethadone is a synthetic µ-opioid receptor agonist that has a stronger affinity for δ opioid receptors than morphine . MethadoHowever, the application of methadone in cancer pain treatment remains challenging due to its complicated and inconsistent conversion ratio from pre-switching opioid dose to methadone . AdditioA retrospective study was conducted in patients who used methadone for cancer pain in Zhejiang Cancer Hospital from April 2016 to December 2020.Patients were included if they met the following inclusion criteria: (1) they had methadone prescribed for compromised pain control and/or intolerable opioid-related adverse reactions to opioids, including long-acting morphine and oxycodone, transdermal fentanyl, and patient-controlled analgesia; (2) they had available data on pain control, adverse events, and cost of both methadone and opioid regimens prior to methadone administration. This study conformed with the principles of the Declaration of Helsinki and was approved by the institutional ethics board of the Zhejiang Cancer Hospital (No. IRB-2022-86).Data on patient demographics, cancer diagnosis, disease stage, bone metastasis, pain type, and Karnofsky score were collected. Details regarding previously prescribed opioids, reason for methadone prescription and discontinuation, methods of methadone switching, initial and maintenance doses of methadone, and pain control and adverse events of both methadone and prior opioids were also recorded. Pre- and post-switching analgesia efficacy was assessed and compared using the pain intensity score and daily frequency of breakthrough pain (BTP). Pain intensity scores were measured using the numeric rating scale (NRS) . Successful switching of methadone was defined as adequate pain relief  with no occurrence of intolerable adverse events. Adverse events were assessed using the National Cancer Institute Common Terminology Criteria for Adverse Events (version 5.0) .The oral morphine equivalent daily dose (OMEDD) of long-acting opioids and opioids for patient-controlled analgesia (PCA) was calculated according to the recommendation of opioid equivalences and relative potency of the National Comprehensive Cancer Network (NCCN) clinical practice guidelines for cancer pain . The conCosts of analgesic regimens were calculated based on the costs of disposable infusion devices for electric infusion pumps and drugs for pain control: oxycodone hydrochloride prolonged-release tablets, fentanyl transdermal patches, methadone hydrochloride tablets, sufentanil citrate injection, hydromorphone hydrochloride injection, morphine hydrochloride injection, celecoxib, etoricoxib, and adjuvant analgesics such as gabapentin and pregabalin. Values/costs in Chinese Yuan were converted to US dollars (1 USD = 6.3715 CNY).The Wilcoxon signed rank test was used to compare efficacy and cost before and after methadone switching, and the chi-squared test was used to analyze differences in the incidence of adverse reactions between methadone and other opioids. Binary logistic regression was conducted to evaluate the relationship between successful switching and factors including types of pain, reasons for switching, methods of switching, NRS before switching, BTP before switching, opioids prior to switching, and OMEDD of prior opioids. Odds ratios (ORs), including 95% confidence intervals, were calculated. Subsequently, multivariate analysis was performed to evaluate independent predictors of successful switching using the backward stepwise elimination method. Furthermore, subgroup analysis of subpopulations with compromised pain control was performed. Statistical analyses were performed using SPSS Statistics 23.0, and statistical significance was set at p < 0.05.A total of 90 patients, mostly with neuropathic pain (60.0%), were included Table . The priPrior to methadone treatment, patients were prescribed extended-release oxycodone (61.1%), transdermal fentanyl, PCA, long-acting opioids combined with PCA, or extended-release oxycodone plus transdermal fentanyl Table . Most paA comparison of the actual initial conversion ratio from opioids to methadone and the recommended initial conversion ratio derived from guidelines  is shownThe median pain score of patients with successful switching was significantly decreased from 4.0 (IQR 2.0–5.0) to 2.0 , and the median daily frequency of breakthrough pain was significantly reduced from 3.0 (IQR 0.0–5.0) to 0.0  by methadone. Moreover, switching to methadone significantly reduced the daily cost of cancer pain treatment by 45% from $19.5 (IQR 12.3–46.2) to $10.8 (IQR 7.1–18.7), p < 0.001.Constipation, nausea, vomiting, and dizziness were the most common adverse reactions for both methadone and prior opioids Table . No signApproximately 10–20% of patients experience refractory cancer pain that is poorly responsive to commonly used opioids such as morphine, oxycodone, and fentanyl, or who have dose-limiting intolerable adverse effects , 6, 9. MApproximately three to four patients achieved good pain control after switching to methadone, which is similar to the previously reported conversion success rates of 77.4 , 80.0 2, and 87.The conversion ratio from prior opioids to methadone is crucial for successful switching . There aOur results indicated that methadone-related adverse events were similar to those for opioids prior to switching. The occurrence of urinary retention decreased after patients switched to methadone. Conversely, methadone-related delirium was slightly increased. Numerous studies have reported methadone-induced delirium –36. The SAG and 3DS are two commonly used strategies for switching to methadone . Our stuThis study had some limitations. First, given its retrospective nature, we were unable to obtain an accurate incidence of methadone-associated adverse effects. Second, this study was limited by its small size and single study site. A multicenter, prospective randomized study is necessary to confirm the efficacy and safety of methadone for refractory cancer pain.For patients with refractory cancer pain who are poorly responsive or intolerable to commonly used opioids, opioid switching to methadone has a satisfactory analgesic effect, good safety, and significantly reduced cost. Methadone is an effective choice for patients with refractory cancer pain, although comprehensively evaluating and closely monitoring adverse reactions remains necessary.


The VAS, the Laitinen questionnaire, the Lequesne Index, the Lysholm questionnaire, and the SF-36v2 health survey were used for the clinical evaluation of the patients. Results: In the group of patients who underwent iontophoresis with the use of Perskindol gel introduced from the positive pole, a statistically significant improvement was shown in all the assessed parameters in comparison to the patients who underwent anodic galvanic treatment. Conclusions: The most favorable effect of iontophoresis was observed in the case of iontophoresis with Perskindol gel introduced from the positive pole.Introduction: Osteoarthritis (OA) is one of the most common causes of pain in the musculoskeletal system leading to disability. The basic principle of the therapy is the simultaneous use of pharmacological and non-pharmacological treatments. The aim of this study was to evaluate the effectiveness of galvanic and iontophoresis treatments with Perskindol Active Classic Gel (Perskindol) in patients with OA of the knee joints. Moreover, a comparative evaluation of the effectiveness of the application was performed depending on the selection of the active electrode. Material and Methods: The study included 100 patients with gonarthrosis, treated at the Rehabilitation Clinic of the Białystok University Hospital. Three groups were randomly selected: in group I ( Osteoarthritis (OA) is the most common disease of the musculoskeletal system, leading to impaired performance in daily life, especially among the elderly. According to the WHO, it is one of the most common causes of disability in developed countries. OA can affect any joint, although the knee joints suffer from it most often ,2.Pathological lesions in the course of OA are the result of an imbalance between the processes of repair and damage to the cartilage tissue. Although the loss (destruction) of the cartilage tissue is fundamental, the disease affects the entire joint. The disease is progressive, conditioned by individual variability and external factors. Clinical symptoms include pain, stiffness, limited mobility, and muscle weakness. Long-term consequences include impairment of physical activity and physical condition, deterioration in the quality of sleep, fatigue, depression, and disability ,4.OA therapy strategies include combined pharmacological and non-pharmacological treatments ,6,7.The aim of the therapy, in addition to pain control, is to improve joint function and activate the processes of cartilage repair. Much attention is paid to the role of the patient in establishing an individual therapy plan, including education of both the patient and his or her immediate environment, providing orthopedic equipment, and rehabilitation. Physiotherapeutic treatment should be implemented as early as possible, and in the first stage of treatment ,7. PhysiThe selection of methods and the course of treatment depend on a number of factors, including age, sex, the degree of advancement of degenerative changes, and coexisting diseases. The therapeutic approach should be individually tailored to the needs and physical condition of the patient, and aimed at improving the quality of life and postponing or, if possible, avoiding surgery ,8. PhysiIontophoresis, due to the introduction of medicinal ions of certain chemical compounds undergoing electrolytic dissociation by force of an electric field, thereby reaching deeper tissues through the skin or mucosa, is a treatment having strong analgesic, anti-inflammatory, and anti-swelling effects. Proper selection of the active electrode is crucial. If an anion is the active ingredient of the drug, the active electrode under which the drug should be placed will be the cathode (“−”), whereas if a cation is the active substance, the drug will be introduced from the anode (“+”). The ions of the substance penetrate the skin through the path of least resistance, i.e., mainly through the sweat glands. It should be emphasized that the advantage of iontophoresis is the fact that a high concentration of the drug can be obtained in the target tissue without the need for oral administration, resulting in a reduced risk of overdose and side effects ,13,14,15Several factors influence the effectiveness of the iontophoresis treatment. These include, among others, the physicochemical properties of the compound, i.e., the particle size and charge, the concentration of the substance, and/or the presence of other ions in the preparation. The equipment used for the procedure, the intensity and type of the current flow, the type of electrodes used, and the duration of the procedure are also important. The effect of the therapy also depends on biological factors, such as skin surface area and temperature, and regional blood flow .In the present work, Perskindol Active Classic Gel with a double cooling and warming effect was used for the iontophoresis treatment. The unique, two-step effect of Perskindol gel relies on the cooling and pain-reducing effect due to the menthol content, which activates the cold receptors, and cools and raises the sensitivity threshold of local pain receptors. The next stage is a long-lasting warming and relaxing effect impacting the tense muscles. This is possible due to the essential oils, which have a warming effect and improve microcirculation, positively influencing local metabolism and fostering tissue regeneration ,17,18.The natural active ingredients of Perskindol gel, such as menthol, pine needle essential oil, and gaultheria and terpinolen essential oils, act directly on the tissues by penetrating the epidermal barrier. The essential oils in the Perskindol preparation reduce the intensity of pain and have anti-inflammatory properties. In addition, massage reduces muscle tension, enhancing the effect of reduced pain and discomfort. Moreover, essential oils positively influence regeneration of periarticular tissues ,34,35,36The aim of the study was to evaluate the effectiveness of galvanic treatment and iontophoresis treatment using Perskindol gel in patients with OA of the knee joints. The intensity of pain, knee joint efficiency and functional efficiency of the lower limb, and the quality of life of the patients were assessed.Due to the lack of data on the recommendations regarding the selection of an appropriate active electrode in the treatment of iontophoresis with Perskindol gel, the next goal was to determine the optimal current polarity for the introduction of the preparation. Thus, a comparative evaluation of the effectiveness of the preparation, depending on the choice of the active electrode, was performed.The study included 100 patients (72 women and 28 men) treated at the Rehabilitation Clinic of the University Hospital of Białystok with diagnosed osteoarthritis of the knee joints. The severity of the lesions was determined according to the Kellgren–Lawrence scale ,39,40,41n = 33), anodic galvanic treatment was performed, whereas in groups II (n = 33) and III (n = 34), the iontophoresis procedure was performed with the use of Perskindol gel, with group II having the preparation administered from the negative pole (“−” iontophoresis) and group III from the positive pole (“+” iontophoresis).Three groups were randomly selected among the study participants. In group I .Each of the three groups was included in a 10-day physical therapy treatment program that included a weekend break. The PHYSIOMED-Expert stimulator was used to carry out the therapy. The treatment time was 15 min on the first day and 20 min on each subsequent day. The dose of direct current was adjusted according to the patient’s sensation, but the limit value of the current was not exceeded .Each patient was interviewed and underwent a physical examination, taking into account the scales and questionnaires described below ,44,45,46Pain intensity assessment on the Visual Analogue Scale (VAS)—A straight line was used with the starting point of 0 indicating no pain, and the end point of 10 indicating unbearable pain.The Laitinen questionnaire was used to assess pain intensity and frequency, the frequency of taking painkillers, and the limitation of physical activity. Each indicator was assessed according to a score from 0 to 4, where 0 meant there was no problem, and 4 indicated the maximum level of problem severity.The Lequesne Index was used to assess pain intensity and function of the knee joint. It consists of 10 survey questions given to patients with osteoarthritis of the knee. It includes five questions about pain or discomfort, one question about the maximum distance traveled, and four questions about daily activities. The entire questionnaire is rated on a scale from zero to 24, with lower scores indicating less impairment of function.The Lysholm questionnaire is a 100-point scale used to make a subjective assessment of the functional capacity of the knee joint. In the final evaluation, patients having a higher total score have a better functional capacity.SF-36v2 Health Survey—This questionnaire was used for a subjective assessment of the patient’s health and quality of life. The information obtained was summed to measure mental health  and physical health .The following parameters were used to present numerical and ordinal variables: median, lower quartile (Q1), upper quartile (Q3), and minimum and maximum.p < 0.05 were accepted as statistically significant.In the statistical analysis, due to the non-existence of normality of distributions, non-parametric methods were used. When comparing the two dependent variables, the Wilcoxon order of pairs test and the sign test were used. When comparing the three independent variables, the Kruskal–Wallis ANOVA rank test was used with the post-hoc test for multiple comparisons of the rank mean for all the trials. The chi-square test of independence was used to check the relationship between the qualitative features. The McNemar test was used to analyze the relationship between the nominal dependent variables. Differences at the level of The pain intensity level (VAS) before treatment did not differ significantly between the three groups.p = 0.012) . After “−” iontophoresis, it was also reduced by 2 (median = −2), whereas after “+” iontophoresis, pain intensity decreased by an average of 3 (median = −3). The use of “+” iontophoresis caused a statistically significant reduction in pain intensity compared to galvanic treatment  , Table 1Before the treatment, there were no statistically significant differences between the groups.p = 0.044). A statistically significant better effect in reducing pain intensity was obtained after “+” iontophoresis compared to “−” iontophoresis   was shown. After “−” iontophoresis, pain intensity also reduced by 2 (median = −2), whereas after “+” iontophoresis, pain intensity decreased by an average of 3 (median = −3). A statistically significant better effect in terms of pain reduction was obtained after “+” iontophoresis compared to anodic galvanic treatment  , Table 1Before the treatment, there were no statistically significant differences between the groups.p = 0.033) . After “−” iontophoresis, the score decreased by 3 (median = −3), whereas after “+” iontophoresis, the score decreased by an average of 5 (median = −5). A statistically significant better effect was obtained with the use of “+” iontophoresis compared to anodic galvanic treatment  , Table 1Before the treatment, there were no statistically significant differences between the three groups.p = 0.014) . After “−” iontophoresis, the score increased by 9 (median = 9), whereas after “+” iontophoresis, the score increased by an average of 12 (median = 12). A higher score was obtained with “+” iontophoresis than with anodic plating, with the statistical significance maintained compared to galvanic treatment  , Table 1The Physical Component Summary (PCS). There were no statistically significant differences between the applied forms of treatment.The Mental Component Summary (MCS). Statistically, the MCS score before treatment did not significantly differ between the three groups. After the galvanic treatment, the MCS score decreased on average by −0.13 (median = −0.13). After “−” iontophoresis, the score increased by 3.78 (median = 3.78), whereas after “+” iontophoresis, it increased by an average of 5.10 (median = 5.10). A statistically significant and better effect of MCS growth was obtained after “+” iontophoresis compared to anodic galvanic treatment  (= 0.007) , Table 1According to the current recommendations regarding the conservative  treatment of OA, the basic principle of therapy is the simultaneous use of pharmacological and non-pharmacological treatments ,7.In view of the numerous limitations and side effects associated with pharmacological treatment, increasing attention is being paid to non-pharmacological methods of treatment that ensure the effectiveness and safety of the therapy .In the present study, the effectiveness of direct current treatments  was assessed in a group of 100 patients with osteoarthritis of the knee joints. The following parameters were assessed: pain intensity, functional efficiency, and quality of life. Moreover, an attempt was made to determine the most favorable current polarity in the iontophoresis procedure with the use of Perskindol gel.In the first group, anodic galvanic treatment was performed. In the second group, iontophoresis was performed with the use of Perskindol gel, with the preparation administered from the negative pole of the current (“−” iontophoresis), whereas in the third group, the iontophoresis procedure was performed with the same agent given from the positive pole (“+” iontophoresis).The literature shows that applying direct current leads to an improvement in vascular flow and a decrease in neuromuscular excitability. Additionally, iontophoresis introduces healing ions into the tissues. The great advantage is the non-invasive nature of the treatment and the fact that even a small concentration of the preparation can bring about the desired effect. It is not without significance that the medicinal product can be administered directly onto the affected tissue, bypassing the internal organs and avoiding side effects ,13,15.Moreover, the administration of drugs with the use of iontophoresis is recognized as an alternative in the treatment of OA .To our knowledge, no studies have been performed with Perskindol gel administered via the skin using iontophoresis. The subject of the present study was the evaluation of the clinical effectiveness of iontophoresis in patients with OA of the knee joints.The literature quotes studies on the use of iontophoresis with NSAIDs and steroid drugs in the treatment of patients with OA ,12,13,42Perskindol gel, due to the topical application of essential oils such as levomenthol, wintergreen oil, or Scots pine oil, has a multidirectional impact on tissues ,34,35,36In the case of patients with OA, the analgesic effect is extremely important, as it reduces the sensitivity of nociceptor receptors and increases the pain threshold, in addition to stimulating and increasing the activity of thermoreceptors and sensory fibers in the skin and subcutaneous tissue ,33,34,35Although OA has the limited characteristics of an inflammatory disease of a local nature, the anti-inflammatory effects of Perskindol also play an important role. In addition to direct inhibition of the inflammatory process , inhibition of the release of inflammatory mediators and the impact on the synthesis of prostaglandins play an important role in treatment. Furthermore, levomenthol, one of the ingredients of Perskindol, increases the absorption of salicylates, which contributes to the enhancement of the anti-inflammatory effect ,34,36.The significant therapeutic importance of levomenthol is clear in the activation of endogenous opioid-dependent analgesic pathways which, given their local anesthetic properties, allow an analgesic effect to be obtained. This helps to increase the range of joint mobility. Moreover, increasing skin blood flow improves blood supply and local metabolism in the treated tissues ,18,30.Other therapeutic effects of Perskindol ingredients include the improvement in peripheral circulation and microcirculation, leading to an acceleration in metabolism in the tissues, the removal of harmful metabolic products, and an improvement in tissue oxygenation .Several other effects of Perskindol ingredients should also be emphasized, such as a reduction in muscle tension, the acceleration of regenerative processes, and relaxing and stress-relieving effects through the influence on the limbic system .The richest source of plant-based salicylates in Perskindol is wintergreen oil, with its analgesic and anti-inflammatory properties resulting from the inhibition of prostaglandin and nitric oxide synthesis (antioxidant effect) ,31,32.Pine oil and other oils such as bergamot oil, lavender oil, citrus oil, orange peel or rosemary oil also have anti-inflammatory and analgesic properties ,28,29,35The study showed that the applied physical therapy resulted in a reduction in pain assessed on the VAS. Improvement was shown in all groups, although a better effect was obtained after “+” iontophoresis.The Laitinen questionnaire showed a reduction in pain intensity and frequency, less frequent use of painkillers, and an improvement in physical activity in all groups of patients, although a more favorable effect was obtained after “+” iontophoresis.In this study, the Lequesne Index was used to assess pain intensity and function of the knee joint. A higher score on this scale indicates a higher degree of impairment of the knee joint. After the therapy, the functional state was improved and pain intensity was reduced in all groups of patients. A statistically significant better effect was obtained after “+” iontophoresis.The Lysholm questionnaire, which was also used in the study, showed an improvement in the subjective assessment of the functional capacity of the knee joints among all the respondents. In all groups, there was a statistically significant difference in scores before and after the treatment. When comparing the three treatments, a statistically significant increase in the number of points was obtained after iontophoresis from the “+” anode.The SF-36v2 Health Survey, consisting of 36 questions, was used to assess the quality of life of patients with chronic OA of the knee joints. It provides an eight-step profile of results, allowing for a summary of the physical and mental components.Although there were no significant differences in the sum of the physical components (PCS) between the proposed treatments, the highest median score was obtained in group III (“+” iontophoresis), of 3.91.In terms of the mental components (MCS) score, a statistically significant increase in the score was obtained after “+” iontophoresis.The obtained effects indicate the effectiveness of Perskindol in the treatment of patients suffering from chronic OA of the knee joints, with the best therapeutic effect obtained after iontophoresis with Perskindol gel introduced from the positive pole.It is very important to undertake comprehensive therapy of the knee joint to prevent functional changes in other adjacent joints, e.g., in the joints of the feet, which may be affected by RA, as they play a very important role in maintaining proper body posture and movement ,49,50.In the group of patients who underwent iontophoresis with Perskindol gel introduced from the positive pole, statistically significant improvements in the degree of pain intensity, functional capacity, and performance of the knee joints, in addition to an improvement in the quality of life, was demonstrated in relation to the patients who underwent the anodic galvanic treatment.In the group of patients receiving iontophoresis with Perskindol gel introduced from the positive pole, a significant improvement was achieved in the degree of pain intensity, as assessed according to the Laitinen questionnaire, in relation to the patients treated with iontophoresis with the use of this preparation applied from the negative pole.In the studied group of patients with OA of the knee joints, the most favorable therapeutic effect was obtained using iontophoresis with the use of Perskindol gel introduced from the positive pole.Taking into account the above results, it is worth considering the use of Perskindol gel during iontophoresis procedures in patients with osteoarthritis of the knee joint.


Regarding the quality of life, physical function (p = 0.001), general health (p = 0.03), social function (p = 0.04), and mental health (p = 0.006) showed better patterns in the sport group than no-sport group. Moreover, neuropathic pain was reduced in the sport group according to the Neuropathic Pain Symptom Inventory (p = 0.001) and ID-PAIN (p = 0.03). The other administered questionnaires showed no significant differences. Our study confirms that CMT1A patients, who practice sports, with a similar severity of disability, may have a better physical quality of life while suffering less neuropathic pain than their peers who do not practice sports. Results recommend the prescription of sport in CMT1A patients.The present study aims to investigate the benefits induced by physical activity/practiced sport in Charcot-Marie-Tooth 1A (CMT1A). Patients were divided into sport and no-sport groups according to their sports performance habit. Thirty-one patients were enrolled, of which 14 practiced sports and 17 did not. Clinical assessments were administered to evaluate disability, self-esteem, depression, quality of life, and pain. Statistical analysis revealed significant differences in terms of gender in the no-sport group compared to the sport group ( Sport is a valuable tool for improving the sense of wellbeing and quality of life, as well as reducing the social barriers of discrimination for disabled people . Beyond Charcot-Marie-Tooth disease (CMT) is a hereditary sensory and motor neuropathy, characterized by genetic heterogeneity with a clinical phenotype of different severity, characterized by distal limb muscle deterioration and weakness, usually with skeletal deformities, distal sensory loss, and abnormalities of deep tendon reflexes .The subdivision into demyelinating CMT1 and axonal CMT2 types is still valid for the majority of patients. CMT1A type represents 60–90% of CMT1 patients and 40–50% of all CMT patients [Currently, there is no defined pharmacological therapy for this pathology. Past trials investigating the possible therapeutic efficacy of ascorbic acid in CMT failed ,11,12,13Rehabilitation and surgical treatment, although without any defined protocol, remain to date the only options, while, for both interventions, there is no consensus about the best practice to recommend. Specifically, a common view lacks for rehabilitation programs and physical exercises to suggest despite general benefits of physical activity are known ,17.Sport could be a valid and more appealing integration to propose to these subjects, while also considering the early onset of syndrome. On the other hand, subjects affected by severe progressive genetic neuromuscular disease are usually considered by physicians and caregivers as unable to carry out sports activities, especially if a whole-body muscular effort is required. However, physicians arbitrarily recommend avoiding supramaximal exercise, when they rarely suggest patients to perform sports.The purpose of this study was to analyze the impact of practiced sport on patients with CMT1A by investigating motivational effects, self-esteem, depression, quality of life, and pain, thus acquiring evidence on the role of sports as complementary therapy for CMT1A subjects.In this study, 31 subjects affected by CMT1A were enrolled. Patients were divided into two groups: sport group (SG), which practiced sports for at least 6 months before the study onset for a frequency of at least 1 h/week and practiced with regularity; no-sport group (NSG), which did not currently practice sports. Inclusion criteria were as follows: (1) age > 18 years old; (2) clinical diagnosis and genetic confirmation of CMT disease; (3) Barthel index (BI) ≤90. Exclusion criteria were as follows: (1) inability to read, understand, and sign the informed consent form; (2) inability or unwillingness to complete the questionnaires; (3) having participated in clinical trials with experimental drugs in the 6 months prior to the study onset; (4) modification of pharmacologic therapy and rehabilitative treatment in the 6 months prior to the study; (5) hospitalization for acute events in the last 6 months; (6) sever concomitant diseases ; (7) other conditions potentially affecting the peripheral nervous system ; (8) drug use with side-effects involving the peripheral nervous system.CMT patients were enrolled in two different settings: outpatients consecutively evaluated for usual follow-up in dedicated clinical practice of highly specialized hospitals; members of Italian CMT patients’ social association (ACMT-Rete).Data were obtained, anonymously, from patients who accepted to participate in the study and signed the informed consent. The study was conducted according to the Helsinki declaration on Ethical Principles for Medical Research Involving Human Subjects, and it was approved by the local ethics board (Prot. n. 5/26.12.2017_FDG). Questionnaires, as described below  sport and motivational effects of physical activity performance; (b) self-esteem, depression, and quality of life; (c) pain.For the SG, data on sports habits were collected: (1) kind of sport; (2) length of period of practiced sport (in terms of months); (3) weekly frequency; (4) weekly timing of workout (min); (5) perceived benefits from sport; (6) participation in competitions. Moreover, data on available services were acquired: (1) facilities to practice sports in own neighborhood; (2) social network to engage sports and meetings among sports practitioners; (3) regularity; (4) perceived effort to practice.For the evaluation of the motivational effect of physical activity, administered only to SG, Behavioral Regulation Exercise Questionnaire-2 (BREQ-2) was used. BREQ-2 includes 19 items, divided into different subclasses: amotivation, external regulation, introjected regulation, identified regulation, and intrinsic regulation. Responses were scored on a five-point scale ranging from 0 (“not true for me”) to 4 (“very true for me”). The mean of the five retrieved subscales was calculated on a five-point scale to evaluate the extent of each motivation type separately .Self-esteem was assessed through the Rosenberg Self-Esteem Scale (SES), a 10-item scale that measures global self-worth by measuring both positive and negative feelings about self: 10–16 is indicative of a low self-esteem; 17–33 is indicative of an adequate self-esteem; 34–40 is indicative of a high self-esteem .Depressive symptomatology was evaluated through Beck Depression Inventory II (BDI-II), a self-report tool consisting of 21 items, divided into two factors: somatic–affective factor and cognitive factor of depression. The total score ranges between 0 and 63: 0–13 indicates a minimum depressive level; 14–19 indicates a medium level; 20–28 indicates a moderate level; 29–63 indicates a severe level of depressive symptoms .Quality of life (QoL) was evaluated through the 36-item Short-Form Questionnaire (SF-36). This scale is divided into different subclasses , summarized in two main scores: physical composite score (PCS) and mental composite score (MCS). The total score was calculated using specific software . The resThe presence of pain, assessed in the whole sample (both SG and NSG), was investigated using the below-described questionnaires.The neuropathic pain symptom inventory (NPSI) is a self-administered questionnaire specifically designed to evaluate the different symptoms of neuropathic pain. Developed and validated by Bouhassira and colleagues, it includes 12 items: ten descriptors of the different symptoms and two items for assessing the duration of spontaneous ongoing and paroxysmal pain. A total intensity score is calculated as the sum of the scores of the ten descriptors and five subscores that are calculated through the mean scores of the items belonging to each of the five factors identified in the factor analysis . We usedID-PAIN is a six-item self-administered questionnaire whose score ranges from 0 to 5, with higher scores corresponding to neuropathic pain or mixed pain with neuropathic component. The presence of pain limited to the joints  is scored minus 1. A score of −1 means “improbable neuropathic pain”, 1 means “possible neuropathic pain”, 2–3 mean “probable neuropathic pain”, and 4–5 mean “high probable neuropathic pain” .p < 0.05.Descriptive analysis assessing the general characteristics of the whole sample and of each group was performed. Clinical outcomes were analyzed by nonparametric statistical analysis. Between-group comparisons were evaluated using the Mann–Whitney U test or, in the case of dichotomous measurements, a 2 × 2 table chi-square test. The significance level was set at p = 0.04). No significant differences were found in terms of disability evaluated by BI by statistical between-group analysis , with a mean frequency of 2.7 times per week , for 72.9 min of mean workout time ; weekly minutes of workout were 205.7 on average . No study participants took part in any sports competitions throughout or before the study period. All patients declared being easily able to perform sports in their own neighborhood; information on sports facilities and related meetings was equally easy to obtain.Referring to participation level regularity, 49% of patients practiced “enough”, whereas 29% were “high”, 14% were “normal”, and 14% were “low”. p = 0.001), general health (p = 0.03), social function (p = 0.04), and mental health (p = 0.006)  .p = 0.001 and p = 0.03, respectively), as reported in Pain was represented as a potentially neuropathic symptom and characterized by low intensity. Pain in SG resulted less neuropathic according to NPSI and ID-PAIN  was true for CMT . The autThe study results are in line with Vita et al. , reportiThe main limitations of this study are its small sample size, which may be explained by the rare nature of the disease. Moreover, CMT1A patients suffer from a lack of pharmacological therapies and a scarce knowledge of their disease by physicians and healthcare professionals. These are some of the factors that can explain the reduce compliance of patients to respond to a battery of several questionnaires.Furthermore, in order to respect the almost 1:1 ratio between SG and NSG, during the enrollment of patients, we had difficulties in recruiting CMT1A patients that practice some sports because patients are afraid that sports could cause a worsening of their conditions. The importance of this paper is also in disproving this belief. Another important weak point is the absence of randomization, which did not allow understanding the real reasons for the differences between the two groups. In particular, some subjects did not practice sport because of their major impairments or their lower psychological health. Moreover, the main specific scale, Charcot-Marie-Tooth Neuropathy Score (CMT-NS), was not applied because some of the patients were interviewed by telephone. However, the results seem to be consistent and statistically clear. Further studies, perspective and randomized, involving other large, specialized centers, can overcome the important limitations of our present work.Our study confirmed that patients who performed sport, presenting a similar disability, had a better physical QoL and less neuropathic pain compared to those who did not perform sport. These results encourage the prescription of sport in CMT-1A patients and suggest prospective studies in this field.