Introduction: Neck pain is a common musculoskeletal condition frequently treated by physical therapists. The American Physical Therapy Association (APTA) published a clinical practice guideline (CPG) in 2008 with a revision in 2017 to improve the diagnosis and treatment of neck pain. One subset of neck pain in the CPG is “Neck Pain with Mobility Deficits,” also called mechanical neck pain. Little data exists on the adherence of physical therapists to the CPG-recommended treatments for neck pain as well as the outcomes associated with the utilization of the CPG. The purpose of this study is to examine both CPG treatment adherence and associated outcomes in patients treated for mechanical neck pain by physical therapists in the outpatient setting.Methods: Retrospective chart review of patients (n=224) who received physical therapy for neck pain between 2018 and 2022. Data ranges were chosen due to the publication of the CPG revision in 2017. Six interventions for mechanical neck pain from the CPG were examined: thoracic manipulation, cervical mobilization, transcutaneous electrical stimulation (TENS), dry needling, advice to stay active, and scapular resistance exercises. The exclusion criteria were a history of cervical spine surgery. Other data collected included age, sex, characteristics of the evaluating physical therapist, and the number of visits.Results: For CPG treatment adherence, 4.5% of patients received thoracic manipulation, 47.8% of patients received cervical mobilization, 12.5% of patients received TENS, 22.8% of patients received dry needling, 99.1% of patients received advice to stay active, and 89.3% of patients received scapular resistance exercises. There was no significant improvement in pain, range of motion (ROM), and function based on a number of CPG interventions used during the bout of physical therapy (p=0.17 to p=0.74). Patients who were evaluated by a physical therapist who was an Orthopedic Certified Specialist (OCS) were more likely to receive more interventions recommended by the CPG (p<0.01).Conclusion:CPG-recommended treatments are used with varying frequency by physical therapists when treating mechanical neck pain. Thoracic manipulation is rarely used while scapular resistance exercises are frequently used. There was no significant improvement in pain, ROM, or function based on the number of CPG-recommended treatments used during the bout of physical therapy. Neck pain is a common musculoskeletal pathology treated by physical therapists around the world ,2. Neck Common signs and symptoms of mechanical neck pain as listed in the CPG include central and/or unilateral neck pain, limited cervical range of motion (ROM), neck pain that is reproduced at end ranges of ROM, and restricted cervical and thoracic segmental mobility . This diOne recent study found that utilization of neck and low back CPGs was about 70%; however, utilization was not associated with final pain or disability in the study cohort . A greatThe current study is a retrospective chart review of 224 patients from multiple outpatient clinics within a single hospital system from 2018 to 2022. The current study was approved by the University Hospitals Institutional Review Board (IRB) under IRB approval #20220542. Patient charts were gathered by the University Hospitals Clinical Research Center based on having a diagnosis of neck pain (ICD-10 code M54.2) as well as a physical therapy evaluation procedure code . Inclusion criteria include receiving physical therapy for neck pain, being older than 18 years old, attending at minimum two sessions of physical therapy , and fitting best into the CPG category of “Neck Pain with Mobility Deficits” based on information in the patient chart. Exclusion criteria were a history of cervical spine surgery and fitting the CPG categories of “Neck Pain with Radiating Pain” or “Neck Pain with Movement Coordination Impairments.” From a total of 1500 patient charts, 224 patients were found to meet inclusion and exclusion criteria.Data collected include age, sex, number of physical therapy visits, Orthopedic Certified Specialist (OCS) status of the evaluating physical therapist, and the presence or absence of six CPG-recommended interventions for mechanical neck pain . Advice to stay active was defined as any home exercise program (HEP) given to the patient. Each of the six CPG interventions was recorded as present if the intervention was performed at least once during the entire bout of physical therapy. Furthermore, other outcome data include pain before and after physical therapy, total cervical rotation active ROM before and after physical therapy, and Neck Disability Index (NDI) score (listed as a percentage) before and after physical therapy. Total cervical rotation ROM was created by adding up a both right and left rotation to help reduce errors in measuring rotation ROM. Because most post-therapy measurements are obtained in the final session of therapy-a session which was missing for many patients who abruptly discontinued therapy-we also performed a subgroup analysis on outcomes for pain, ROM, and disability as expressed by the NDI to help get a more complete picture.Statistical analysis was performed using SPSS software version 29.0. Frequency counts were used to determining the usage of CPG interventions among the cohort. One-way ANOVA with Tukey posthoc testing was used to compare patients receiving two or less, three, or four or more CPG interventions. The t-test was used to compare the number of CPG interventions used in comparison to the OCS status of the treating physical therapist.Patients (n=224) in the current study had an average age  of 60.7 years 16.2 years) with 71.0% of patients (n=159) being female and 29.0% of patients (n=65) being male. Patients had an average (SD) number of PT visits of 7.1 visits (4.2 visits). Of the entire cohort, 76 patients (n=33.9%) had chronic neck pain, which we defined as pain lasting in duration equal to or longer than 180 days. For treatment selection, 4.5% of patients (n=10) received thoracic manipulation, 47.8% of patients (n=107) received cervical mobilization, 12.5% of patients (n=28) received TENS, 22.8% of patients (n=51) received dry needling, 99.1% of patients (n=222) received a HEP with advice to stay active, and 89.3% of patients (n=200) received scapular resistance exercises  received one intervention, 37.9% of patients (n=85) received two interventions, 41.5% of patients (n=93) received three interventions, 14.7% of patients (n=33) received four interventions, 2.7% of patients (n=6) received five interventions, and none of the patients received all six interventions , range of motion (n=96), and Neck Disability Index disability score (n=77). There was no significant difference in improvement in pain based on the number of CPG interventions used during the bout of PT (p=0.56). However, one-way ANOVA testing revealed a significant difference in the amount of PT visits used for pain outcomes (p<0.01). Patients who received four or more CPG interventions had significantly more visits than patients who received two or less CPG interventions during the bout of PT (p<0.01). There was no significant difference in improvement in ROM based on the number of CPG interventions used during the bout of PT (p=0.74). Furthermore, there was no significant difference in the amount of PT visits used based on the number of CPG interventions used (p=0.21). Finally, there was no significant difference in the improvement in disability per the Neck Disability Index based on the number of CPG interventions used during the bout of PT (p=0.17). However, patients who received four or more CPG interventions had significantly more PT visits with the same outcomes as compared to patients using three or two or less CPG interventions (p=0.02 and p<0.01).To further understand the different therapy utilization rates, patients were divided into groups depending on the OCS status of the treating physical therapist who did the evaluation. The OCS Group (n=16) and the Non-OCS group (n=174) had a significant difference in the amount of CPG interventions used (p<0.01), with the OCS group utilizing more CPG interventions (3.4 interventions compared to 2.7 interventions).Neck pain is a disabling condition that has received much attention in the literature in an effort to improve patient management via the creation and revision of a Neck Pain CPG by the APTA ,2. The cOur data showed that as the number of therapy visits increased, so too did the number of CPG interventions used and that neither of those variables was associated with improvement in pain. There was also a significant association between the increased number of physical therapy visits and the increased number of CPG-recommended treatments utilized during the bout of physical therapy. Depending on the outlook, the increased visits could be a positive or a negative attribute. Increased visits could indicate greater attendance to physical therapy visits because of higher quality physical therapy care, or it could indicate greater waste if the outcomes are the same, despite the increase in visits. Interestingly, that study by Beneciuk et al. found that the overall CPG treatment adherence rate that was relatively high (71.2%), which is contrary to the current study .There are several limitations of the current study. First, the study has a relatively small sample size from a single hospital system. Therefore, the results may not be generalizable to physical therapists across different regions. Furthermore, while the study included patients from multiple outpatient clinics, it is unknown how many physical therapists or physical therapist assistants participated in the treatment of the 224 patients in the study. Therefore, it is unknown if the problem is more widespread among physical therapists or just represents consistent poor adherence among a smaller number of physical therapists. It is also possible that some physical therapists are simply not aware of the current CPG. Strengths of the current study include the retrospective nature of the study compared to the surveys, which has been the usual way of assessing CPG adherence in the literature ,9,10. AcCPG interventions are used with varying frequency in patients treated by physical therapists for neck pain with mobility deficits. Thoracic manipulation is rarely used whereas advice to stay active and scapular resistance exercises are a common part of PT treatment for mechanical neck pain. The number of CPG interventions used during the treatment session did not impact outcomes for pain, ROM, and function. Furthermore, increased CPG intervention usage was associated with increased patient visits, despite no significant improvement in outcomes. Patients treated by an evaluating PT who had their OCS were more likely to be treated with more CPG interventions. More research is needed to determine impact of CPG on outcomes as well as reasons for adherence or non-adherence to CPG interventions.


Knee osteoarthritis affects millions of people worldwide. There remains a role for novel therapies to manage pain for patients who are unable or unwilling to undergo knee arthroplasty. A peripheral nerve stimulator (PNS) may be beneficial in this population. We present a case report of three patients who received temporary femoral or saphenous PNS and were either unwilling or unable to undergo knee arthroplasty. Two of the three patients reported significantly reduced pain and improved functioning. Our case report demonstrates that temporary PNS may offer a safe and effective treatment for chronic knee pain secondary to knee osteoarthritis. Knee osteoarthritis affects more than 650 million individuals worldwide and is a leading cause of disability . After aOne alternative is the use of a peripheral nerve stimulator (PNS). This treatment is increasingly used in clinical practice to treat conditions such as peripheral neuropathy, complex regional pain syndrome, and other acute and chronic pain conditions ,5. ThereTherefore, we would like to present a case report of three patients undergoing temporary PNS for the treatment of osteoarthritic knee pain. This manuscript adheres to the CARE guidelines.Implantation procedureA femoral nerve PNS was performed with the patient in a supine position. The anterior thigh and groin areas were prepped with chlorhexidine and draped in a sterile fashion. The site of needle insertion was chosen just below the femoral crease, approximately 1-2 inches below the inguinal ligament. The skin and subcutaneous tissue over the groin were anesthetized by the infiltration of 1% lidocaine. A 12.5 cm, 20 g SPR Therapeutic Inc. introducer  needle preloaded with stimulating lead was inserted under ultrasound guidance with a linear array probe. Using an in-plane approach, the needle was directed towards the femoral nerve from the lateral to the medial side . Once thFor the saphenous nerve PNS, the patient was again placed in a supine position, and the skin over the area was prepped in a sterile fashion. A linear array ultrasound probe was placed transversely at the junction between the middle and distal thirds of the thigh. Using a lateral to medial in-plane approach, the percutaneous PNS lead was implanted 0.5cm from the saphenous nerve to enable selective activation of large-diameter sensory fibers. Patients tolerated the procedure well, and there were no apparent immediate complications or adverse effects seen in all three patients. Case 1The patient was a 47-year-old female with a history of five years of chronic left knee pain secondary to knee osteoarthritis. Her pain was refractory to conservative therapy, including physical therapy, medication management with ibuprofen, diclofenac gel, and cannabidiol oil, as well as intra-articular injection therapy with steroids and hyaluronic acid. The patient reported a pain score of 7/10 on a numerical rating scale and noted that her pain was sharp and burning, non-radiating, and located in the anterior and medial parts of her left knee. Orthopedic surgery did not recommend surgical intervention, given her age. She was offered a temporary 60-day femoral PNS, which she agreed to pursue. The patient reported an improvement in her pain score to 2/10 immediately after the procedure. Two months after the procedure, her pain remained at a 4/10. She reported a substantial decrease in her ibuprofen usage (20 tablets to 2 tablets per week) and an increase in her ability to rock climb and hike as compared to prior. Case 2The patient was a 47-year-old female with a history of four years of bilateral chronic knee pain secondary to knee osteoarthritis. Her pain was refractory to physical therapy and medication management. The patient initially had relative success with intra-articular steroid injections. However, she noticed that they were working for decreasing amounts of time. An intra-articular hyaluronic acid injection was trialed with no benefit. The patient reported a pain score of 7/10 and noted that her pain was dull, non-radiating, and located in the anterior, medial, and lateral aspects of her knees. Orthopedic surgery did not recommend surgical intervention, given her age and BMI of 45. The patient was offered a temporary 60-day left femoral PNS and agreed to proceed with this procedure. Immediately after the procedure, the patient reported her pain as a 0/10. Two months after the procedure, the patient reported continued 0/10 pain at rest and 2-3/10 with activity. She was able to stop all medication usage and had significantly improved activities of daily living, including driving and walking. Case 3The patient was a 63-year-old male with a history of five years of left chronic knee pain secondary to knee osteoarthritis. The patient’s knee pain was refractory to physical therapy and medication management. The patient had previously had some success with intra-articular steroid injections for three years; however, they subsequently lost effectiveness. The patient also did not benefit from intra-articular hyaluronic acid injections. The patient reported that his pain score was a 4/10 at rest and a 6/10 with activity and noted that the pain was dull, non-radiating, and located over the entirety of the knee. The patient remained on oxycodone 5mg four times a day without significant improvement in his pain. The patient was uninterested in surgery and was offered a temporary 60-day femoral PNS. The patient agreed to proceed with this procedure. During the procedure, the patient experienced significant muscle contractions with stimulation. Due to this, the saphenous nerve was targeted until the patient experienced comfortable paresthesia without muscle contractions. Unfortunately, two weeks after the procedure, the patient reported uncomfortable cramping and inadequate coverage over his painful areas. The PNS was then removed without any complications.This retrospective case series describes three patients with chronic knee pain secondary to knee osteoarthritis. As noted above, two out of three patients were treated with temporary femoral nerve PNS therapy delivered through a single percutaneous lead. One patient was treated with temporary saphenous nerve PNS due to muscle contractions with femoral nerve stimulation. Two out of three patients had improvement in functional status and pain score. One patient had no improvements in functional status or pain scores.In our literature search, we found no reports of the use of femoral PNS for patients with knee osteoarthritis who were unable or unwilling to pursue knee arthroplasty. There has been one case report published detailing a patient with chronic knee pain secondary to knee osteoarthritis who refused total knee arthroplasty . This paFemoral PNS is an effective option for pain management for other indications. Ruak et al. discuss the use of a temporary femoral PNS for a patient with post-amputation pain . The patThere have also been several studies showing the effectiveness of femoral PNS alone or femoral and sciatic PNS for acute postoperative analgesia after either total knee arthroplasty or anterior cruciate ligament reconstruction -14. ThesThere are limitations to our case study. First, this is a retrospective study, and some benefits may be attributed to the placebo effect. In addition, we chose to target only the femoral nerve, though anatomic reviews show that both the femoral and sciatic nerves carry the primary sensory innervation to the knee ,17. WhilOur cases demonstrate that femoral PNS is a viable option to manage chronic pain secondary to knee osteoarthritis in those who are unwilling to undergo knee arthroplasty or are poor candidates for surgery. Our results indicate that further clinical studies, such as a randomized controlled trial, are warranted.


Additionally, patients who experienced pain before or after surgery were more likely to receive opioid refills. Those experiencing moderate or severe pain were 1.66 times more likely to receive a refill . The findings highlight the need to consider surgery-related factors when prescribing opioids and the importance of developing strategies to balance the optimization of pain management with the risk of opioid-related harms.There is growing concern about the over-prescription of opioids and the risks of long-term use. This study examined the relationship between initial need  and dosage of opioids in the first prescription after surgery with continued opioid use through opioid refills over 12 months, while considering patient-level characteristics. A total of 9262 opioid-naïve patients underwent elective surgery, 7219 of whom were prescribed opioids following surgery. The results showed that 17% of patients received at least one opioid refill within one year post-surgery. Higher initial opioid doses, measured in morphine milligram equivalent (MME), were associated with a greater likelihood of continued use. Patients receiving a dose greater than 90 MME were 1.57 times more likely to receive a refill compared to those receiving less than 90 MME (95% confidence interval: 1.30–1.90,  Opioids are frequently prescribed for pain management in the United States, where they are more commonly prescribed than in any other country . HoweverPrescribing opioids to opioid-naïve patients has been identified as a risk factor for continued use and opioid-related adverse events . Even a The objective of this study was to examine the relationship between patient factors and factors related to the first opioid prescription post-surgery, including patient-reported pain, and continued opioid refills for opioid-naïve patients. The study aimed to investigate the impact of opioid prescription dosage, pre- and post-operative pain, and discharge pain on opioid refills in the 12 months following surgery in order to examine continued use. By understanding these factors, the findings of this study can inform clinical practice and guide the development of interventions to reduce the risk of opioid dependence and addiction in opioid-naïve patients who receive opioids for a surgical procedure.Prescription and surgery information for patients was extracted from Prisma Health’s Electronic Health Record (EHR) for the study period of April 2016 through September 2019. Prisma Health is the largest healthcare system in South Carolina, including 18 hospitals and 289 practice sites in Greenville and surrounding counties in the Upstate region.During the study period, 19,754 surgeries were performed in 16 Prisma Health facilities among 18,681 unique patients. A total of 1015 patients were removed from the analysis because they had more than one surgery during the study period. An additional 8404 patients were excluded due to pre-surgery opioid prescriptions, opioid use disorders, histories of chronic pain, non-elective surgeries, and surgeries performed at facilities that joined Prisma Health after the beginning of the study. Thus, the final sample consisted of 9262 opioid-naïve patients undergoing a single elective surgery during the study time . SurgeriThe total daily opioid dosage in the first prescription post-surgery to patients in the cohort was calculated and recorded in morphine milligram equivalent (MME), taking into account all opioids. Standard calculation of MME is the product of the dose (strength multiplied by supply per day) and a conversion factor based on the opioid ,18. The We conducted logistic regression analyses to evaluate the relationship between predictors and the outcome of opioid refills within the 12-month period after surgery. The outcome variable was binary, indicating whether patients did or did not receive any opioid refills during the post-surgery period. The main predictors were MME/day prescribed in the first prescription post-surgery, pre- and post-operative pain, and discharge pain. MME dosage was categorized as greater than and less than or equal to 90, with subjects who did not receive any MME dosage removed from the analysis. The pain variables were binary and based on patient ratings, categorized as none/mild or moderate/severe pain for pre- and post-operative pain and discharge pain. Any pain was calculated based on if pre-operative, post-operative, or discharge pain was moderate/severe.p < 0.05 as statistically significant. Ethical review and approval were waived for this study under Exemption Category 4.The effect of the main predictors (MME daily dosage and pain variables) was individually examined in the unadjusted model. In the adjusted model, we included age, sex, race/ethnicity, elective surgery category, mental health status, tobacco smoking, and tobacco vaping. These variables were included as covariates in the analysis. Statistical analyses were performed using R version 3.6, and we considered The characteristics of the cohort are presented in p < 0.001), indicating that those with MME > 90 were 1.79 times more likely to receive a refill than those in the MME ≤ 90 group. After adjusting for all other covariates and pain, the OR was still significant at 1.57 .The results of the logistic regression analysis that examined the relationship between prescribed MME/day, discharge pain, pre- and post-operative pain, and opioid refills during the follow-up period are provided in p < 0.001), which was significant after adjusting for covariates . Similarly, patients who had moderate or severe post-operative pain were almost twice as likely to get a refill compared to patients with none or mild pain after surgery ; however, this did not show evidence of significance when adjusted for covariates . Those reporting discharge pain of moderate or severe levels were 1.76 times more likely to get a refill compared to those with none or mild discharge pain , and this association remained significant after adjusting for other covariates . Patients who reported severe or moderate pre-operative pain were 1.88 times more likely to get a refill in the follow-up period compared to those with none or mild pre-operative pain ; patients with psychological disorders showed higher odds of receiving a refill compared to those without ; and current and former smokers showed higher odds of a refill compared to the non-smoker group, with odds ratios of 1.80  and 1.19 , respectively. Full adjusted model results for patient-level characteristics can be found in Patient-level characteristics were also predictive of likelihood of a refill. Non-Hispanic Black patients showed higher odds of receiving a refill compared to Non-Hispanic White patients  were prescribed any MME in the first prescription following any elective surgery, with 1208 (17%) getting at least one refill within one year after the surgery. Furthermore, those with greater pain and a higher dosage of opioids showed greater likelihood of obtaining a refill. These overall findings suggest that opioid prescribing practices may contribute to the continued use of opioids, especially in patients receiving them for the first time, and tailoring prescriptions to individual patient needs should be considered. The results from our study demonstrated that the quantity of opioid dosage in the first prescription post-surgery is crucial and could impact the continued use of opioids. In particular, patients with an opioid dosage greater than 90 MME/day were 1.57 times more likely to have a refill compared to those who received a dosage of less than 90 MME. Therefore, the present study adds to a growing body of literature showing a link between opioid prescription and continued use ,23,24,25Pain management is an essential factor that leads physicians to prescribe opioids. Long-term opioid use often begins with treating acute pain , with thAlternative non-opioid medications and opioid prescribing protocols may be of use to minimize risks without jeopardizing pain management. To give some examples, a shift to use of ketamine instead of opioids during surgery, a decrease in the availability of opioid dosage vials, EHR notifications to alert prescribers to high doses, and limitations to the duration of post-surgery prescriptions have been shown to be effective at reducing the MME prescribed post-surgery without compromising patient pain . HoweverProviders must also ensure that they do not produce unnecessary pain for patients by not prescribing opioids . Given tThere are a few limitations to the present study that should be noted. First, the study was carried out in a single health system located in the Upstate region of South Carolina where the population is predominantly white. Thus, it may not be appropriate to apply our findings to other contexts. Second, we were unable to consider other variables that could have an impact on opioid prescription practices, including provider attributes and patient preferences. Furthermore, although we collected data on refills, we were not able to confirm whether patients actually used the prescribed opioids . SimilarGiven the risk of opioid misuse following surgery among patients previously opioid-naïve, characteristics of the surgery, including the patient’s need for pain management and MME prescribed, are necessary factors to consider in examining and preventing the threat of continued use. The present study provides evidence that high opioid prescription doses, pre-and post-operative pain, and discharge pain are associated with a higher likelihood of opioid refills in the 12 months following elective surgery in opioid-naïve patients. The results also showed that patient-level factors, including race, other substance use, and psychological disorders predicted likelihood of obtaining a refill. Strategies and guidance related to refill access are underexplored, particularly among opioid-naïve patients. The findings highlight the need for careful consideration of patient and surgery-related characteristics when prescribing opioids and the importance of developing strategies to balance optimization of pain management with risk of opioid-related harms.


To systematically compare the bowel cleaning ability, patient tolerance and safety of oral sodium phosphate tablets (NaPTab) and oral polyethylene glycol electrolyte lavage solution (PEGL) to inform clinical decision making.PubMed, Embase, CBM, WanFang Data, CNKI, and VIP databases were searched for studies that used randomized controlled trials (RCTs) to compare the roles of NaPTab and PEGL in bowel preparation before colonoscopy. Two reviewers independently screened the studies, extracted data, and assessed the risk of bias in the included papers. A meta-analysis was performed using RevMan 5.3 software.P = 0.46]. The incidence of nausea was lower in the NaPTab group than in the PEGL group . Patients rated the taste of NaPTab higher than PEGL . Willingness to repeat the treatment was also higher in the NaPTab group than in the PEGL group . Both serum potassium and serum calcium decreased in both groups after the preparation; however, meta-analysis revealed that both minerals decreased more in the NaPTab group than in the PEGL group . Meanwhile, serum phosphorus increased in both groups after the preparation; however, levels increased more in the NaPTab group than in the PEGL group .A total of 13 RCTs were eligible for inclusion, including 2,773 patients . Meta-analysis revealed no significant difference in the cleansing quality of the NaPTab and PEGL groups [RR 1.02, 95% CI (0.96–1.08), While NaP tablets and PEGL were shown to have a similar cleaning effect before colonoscopy, NaP tablets had improved patient tolerance. However, NaP tablets had a strong effect on serum potassium, calcium, and phosphorus levels. For patients with low potassium, low calcium, and renal insufficiency, NaP tablets should be prescribed with caution. For those at high-risk for acute phosphate nephropathy, NaP tablets should be avoided. Given the low number and quality of included studies, these conclusions will require additional verification by large high-quality studies.10.37766/inplasy2023.5.0013, identifier: NPLASY202350013. Ideal bowel preparation allows for a detailed examination of the entire colon and should be safe and acceptable to patients. Insufficient bowel preparation is a cause of incomplete colonoscopy. Polyethylene glycol electrolyte lavage solution (PEGL), for example, is associated with inadequate cleaning rates of ≥10% . InsuffiOral sodium phosphate tablets (NaPTab) are convenient and associated with a lower incidence and severity of nausea than OSP solution . The curThe registration number of the systematic review protocol was INPLASY202350013 in the INPLASY.Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were used to conduct this meta-analysis . A systeBox 1#1 colonoscopy#2 bowel preparation OR bowel cleaning#3 sodium phosphate OR sodium phosphate tablets#4 polyethylene glycol electrolyte lavage solution OR polyethylene glycol#5 #1 AND #2 AND #3 AND #4The inclusion criteria included (1) patient populations with an indication for colonoscopy, including outpatients or inpatients requiring diagnosis or treatment (those receiving a sigmoidoscopy were not considered), (2) randomized controlled trial (RCT) study designs, (3) a sodium phosphate tablet intervention group, (4) a control group receiving PEGL administered orally or by nasogastric tube, (5) outcome measures including cleansing quality, adverse effects (incidence of nausea), patient acceptance (taste and willingness to repeat the treatment), and changes in serum electrolytes after preparation, and (6) all included articles were available in English.The exclusion criteria included (1) articles that were not rigorous or had incomplete data, (2) trials of bowel preparation treatments other than NaPTab and PEGL, (3) repeated publication of the same study, and 4)not in the English language.Two reviewers (Li Yao-dong and Zhou Zuo-qiong) independently screened the literature, extracted data and cross-checked studies that met both the inclusion and exclusion criteria. Differences were solved by discussion or consultation with a third reviewer . The researchers began by reading the titles of the articles and excluding any studies that were obviously irrelevant before reading the abstract or full text of remaining articles to determine whether or not they should be included. Extracted data primarily included: basic report information , methodology , outcome evaluation indicators (including adverse drug events and adverse drug reactions) and key elements associated with a risk of bias.Quality assessment was performed using the Cochrane risk-of-bias tool, which consists of a random distribution method, a distribution hiding method, a blind method, incomplete results and other deviations. Each study was rated as “yes” (low risk of bias), “no” (high risk of bias) or “unclear” (uncertain risk of bias) .p > 0.10, I2 < 50%) then the fixed effect model was used for analysis. When p < 0.10 and I2 ≥ 50%, a random effect model was used for analysis. Sensitivity analysis were used to handle obvious clinical heterogeneity. Publication bias was assessed through the visual check of funnel plots.Meta-analysis was conducted using RevMan5.3 software. Quantitative data were presented as the relative risk degree (RR) and 95% confidence interval (CI). Measurement data included the mean difference (MD) and 95% CI as the effect index. The chi-square and I-square tests were used to measure heterogeneity in the trials (the test level was α = 0.05). If there was no obvious heterogeneity , so the random effect model was used for analysis. Meta-analysis results showed that the ratio of excellent and good bowel cleaning quality was similar between the NaPTab and PEGL groups   , 21–23.  = 0.46] .P = 0.93, P = 0.49 accordingly] , p = 0.003]  so the fixed effect model was used for analysis. Meta-analysis results showed that nausea incidence was lower in the NaPTab group than in the PEGL group  , so the fixed effect model was employed for analysis. Meta-analysis results showed that the taste rating of the NaPTab group was higher than the PEGL group  , so the random effect model was used for analysis. Meta-analysis results showed that the NaPTab group had a higher willingness to repeat the treatment than the PEGL group   so the random effect model was used. Meta-analysis results showed that the NaPTab group had a greater decrease in serum potassium than the PEGL group   so a random effect model was used. Meta-analysis results showed that the decrease in serum calcium was greater in the NaPTab group than in the PEGL group   so the random effect model was employed. Meta-analysis results showed that the NaPTab group had a greater increase in serum phosphate than the PEGL group  (Two articles including 438 patients assessed the change in serum phosphorus (inorganic) before and after colonoscopy preparation , 14. Whi0.00001] .A sensitivity analysis of adequate cleansing quality by omitting one study at a time did not fundamentally influence the pooled RR, suggesting that the combined RR was valid and credible. No evidence of publication bias was observed when the difference of adequate cleansing quality between NaPTab and PEGL were assessed .Colonoscopy has been used in medicine for over half a century. Many primary hospitals are now implementing this technique since it allows direct examination of the colonic mucosa. However, inadequate bowel preparation can make it difficult to clearly observe mucous membranes , resultip = 0.003), but only two studies was included. The NaPTab group also had a lower incidence of nausea, a higher excellent and good taste rating and a higher willingness to repeat the treatment than the PEGL group, and these differences were significant. Two trials including 438 patients detected changes in serum potassium, calcium, and phosphorus levels before and after intestinal preparation. Serum potassium and calcium levels decreased after intestinal preparation with both treatments but the change was statistically greater for the NaPTab group than the PEGL group. Meanwhile, blood phosphorus increased following both treatments but the rise was significantly higher for the NaPTab group.The current study collected 13 RCT studies that compared the success of intestinal preparation using NaPTab or PEGL prior to colonoscopy. Eight trials including 2,605 patients compared the effects of intestinal cleaning. Meta-analysis results showed that the NaPTab group was more likely to have an excellent and good rating of intestinal cleaning quality than the PEGL group ; however, the difference was not significant. Subgroup analysis showed that the NaPTab subgroup of more than 32 had a higher excellent and good rating of intestinal cleaning quality than the PEGL group  was developed. Large doses of ascorbic acid that are not fully absorbed remain in the colon cavity, where it plays an osmotic role, so a small amount of PEG is required .Changes in electrolyte levels are more obvious for patients in the NaPTab group after intestinal preparation. This is a particular concern for high blood phosphorus, which is associated with severe kidney damage. A study identified 21 patients with acute renal failure a few weeks after a colonoscopy preparation using OSP. While renal function improved for most patients, four patients required renal replacement therapy . In addiThere are various ways for bowel preparation before colonoscopy, and different population need different volume of lavage or dose possibly. Westerners are heavier in body weight and need larger in dose when preparing. In addition, many cases require individualized bowel preparation based on risk factors. There are many risk factors for poor intestinal preparation, such as history of abdominal surgery. There are some possible explanations for the poor intestinal preparation in patients with a history of abdominal surgery. First of all, the patient has a decreased intestinal motility after intestinal resection. Second, after abdominal surgery, intra-abdominal adhesion may lead to the fixation of flexible intestine, which may lead to local retention of fecal substances. A study shown that gastric/small intestinal surgery was a potential risk factor for poor bowel preparation . AccordiIn conclusion, the current meta-analysis showed that NaPTab and PEGL have a similar cleaning effect before colonoscopy and that the tolerance of NaPTab is superior to PEGL. However, NaP tablets have a stronger effect on serum potassium, calcium and phosphorus levels. For patients with low potassium, low calcium and renal insufficiency, NaP tablets should be prescribed with caution. For patients at high risk for acute phosphate nephropathy, NaP tablets should be avoided. These conclusions are limited by both the number and quality of included studies and require verification by larger and more high-quality studies. Individualized bowel preparation based on risk factors is required for special cases. Good cleaning effect, low capacity, good taste, few adverse reactions and high security are goals to consider for the design of future intestinal preparations before colonoscopy. More clinical trials are required to evaluate relevant drugs or methods.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.All authors listed have made a substantial, direct, and intellectual contribution to the work and approved it for publication.


OPRM1, COMT, SLC6A4, ABCB1, and CYP2B6 genes, on the intra-operative consumption of remifentanil and propofol, as well as the postoperative analgesic needs, in patients subjected to thyroidectomy surgery.Perioperative anesthetic and/or analgesic demand present considerable variation, and part of that variation appears to be genetic in origin. Here we investigate the impact of common polymorphisms in We conducted a prospective cohort study with 90 patients scheduled to undergo elective thyroidectomy, under total intravenous anesthesia achieved by target control infusion (TCI) of propofol and remifentanil. Postoperative analgesics were administered by protocol and on-demand by the individual patient. Genotyping was established by PCR–RFLP methods. Genotyping data, intra-operative hemodynamics, and total consumption of remifentanil and propofol, as well as postoperative analgesic needs and pain perception, were recorded for each individual.ABCB1 3435TT genotype appeared to experience significantly less pain within one hour post-operatively, compared to C carriers , a finding limited to those seeking rescue analgesic treatment. Intra-operatively, homozygotes patients for the minor allele of OPRM1 A118G and CYP2B6 G516T appeared to consume less remifentanil  and propofol  but the difference was not statistically significant in our sample.Patients with the ABCB1 C3435T polymorphism appears to affect the postoperative perception of surgical pain among patients with low pain threshold. The small number of minor allele homozygotes for the OPRM1 A118G and CYP2B6 G516T polymorphisms precludes a definitive conclusion regarding the inclusion of the latter in a TCI-programming algorithm, based on the results of this study.The ACTRN12616001598471.The online version contains supplementary material available at 10.1007/s43440-023-00455-7. Remifentanil is a synthetic μ-opioid receptor OPRM1) agonist with rapid onset and short duration of action. It displays fast biotransformation by blood esterases and its context-sensitive half-time  is very short, independent of the duration of infusion, and apparently unaffected by liver or kidney function impairment  agonist . Thus, rA receptors as an agonist. It is extensively metabolized, primarily in the liver, but also in the kidneys and the small intestine, mainly by CYP2B6 and UDP glucuronyl transferases (UDPs) .–28.24–28χ2 goodness-of-fit test. The effect of each polymorphism on time- and weight-normalized logarithmically transformed remifentanil consumption was tested with ANCOVA, using age, sex, height, Hamilton anxiety scale, and time- and weight-normalized propofol consumption as covariates. The effect of polymorphisms on time- and weight-normalized propofol consumption was examined with the Jonckheere-Terpstra test, due to the wide deviation of propofol consumption from normality which could not be corrected with logarithmic transformation , initially using all three genotypes of each polymorphism as independent variables, and pairwise comparisons as required. The same type of analysis was applied to test the effect of genotypes on VAS, at different time points, from 15 to 360 min following extubation. Spearman’s correlation tests were used to assess the correlation between intra-operative and postoperative drug consumption with VAS at all time points. IBM SPSS statistics 27 was the latest version used for statistical analyses. Bonferroni correction for five polymorphisms and three dependent variables  returns a significance limit of 0.003.All continuous variables were tested for normality with the Kolmogorov-Smirnoff test. Deviation of genotype distributions from the Hardy–Weinberg equilibrium was tested with the OPRM1 A118G and CYP2B6 G516T genotyping failed for an additional one and 11 patients, respectively. All genotype distributions were consistent with the Hardy–Weinberg equilibrium.Patients’ demographic characteristics and genotype distributions for the five polymorphisms are shown in Table p = 0.001; Table S1), and with VAS ratings at all time points (Table S2). VAS distributions also deviated significantly from normality.Intra- and postoperative analgesic/anesthetic drug consumption, as well as VAS pain ratings, are summarized in Table OPRM1 A118GG genotype in comparison to those carrying the AA and AG genotypes . Similarly, CYP2B6 516TT genotype carriers appeared to consume less propofol compared to CYP2B6 516GG and GT carriers intra-operatively , but, here again, the difference was not significant . As a significant number of patients  required rescue analgesic treatment suggesting a lower pain threshold (Table S3), the analysis was repeated following stratification accordingly. As shown in Fig. ABCB1. C3435T genotype distributions did not differ between the two subgroups (Table S4). Finally, because anxiety is known to affect the perception of pain and Hamilton rating scale values were positively correlated with postoperative analgetic consumption, we have examined the effect of the ABCB1 C3435T genotype on Hamilton ratings, with negative results (Table S5).The effect of each polymorphism on VAS ratings obtained at 15, 30, 60, 120 and 360 min after completion of surgical procedures was probed next. Results are displayed in Table ABCB1 C3435T on post-surgical pain perception; patients carrying the TT genotype apparently reported significantly lower pain perception compared to C carriers, at times 15, 30 and 60 min following the end of the surgical procedure, when VAS ratings are highest and most varied. Furthermore, that effect was detected only among those patients requiring rescue analgesic medication, i.e., with a low pain threshold. We argue that the fact that the significance of this association appears to be time-dependent and rather consistent throughout most of the postoperative period argues against it being a chance finding. Since neither VAS ratings nor the ABCB1 C3435T polymorphism is associated with intra-operative consumption of remifentanil or propofol, one should look into postoperative analgesic consumption or the mechanism of pain perception for an explanation. As VAS ratings are consistently higher in patients requiring additional (rescue) postoperative treatment (Table S5), the former must reflect either differences in the interindividual efficiency of standard postoperative paracetamol or in some physiologic parameter causally related to pain perception. Paracetamol is known to induce ABCB1 expression [ABCB1 3435TT genotype is associated with increased threshold to heat pain in opioid-free adults with chronic pain. The authors attributed that apparent effect on alterations in the efflux of endogenous opioid peptides from the brain, previously shown to be mediated by ABCB1 [ABCB1 3435TT genotype is also associated with a lower perception of pain and that this effect is made apparent only among those patients predisposed to higher pain sensitivity . That would be consistent with a situation where the concentration of opioids in the CNS becomes limiting and is thus affected by transport systems in the blood–brain barrier, including ABCB1.While the primary objective of this study was to examine the effect of common polymorphisms previously related to opioid and propofol efficiency on intra-operative remifentanil and propofol requirements (consumption) of by patients who had undertaken elective thyroidectomy, its main—and rather unexpected—finding was a time-dependent effect of pression  but was pression  suggesteOPRM1 118GG genotype consumed low amounts of remifentanil, and so did five out of six patients with the CYP2B6 516TT genotype with respect to propofol. A small number of studies have examined the association of the same OPRM1 polymorphism with intra-operative opioid  requirements, all of them involving obstetrics analgesia [reviewed in [OPRM1 A118G on remifentanil requirements thus far, with the exception of a single report highlighting a protective effect of the maternal G allele on neonates whose mothers had received remifentanil in the context of labor anesthesia [CYP2B6 G516T on propofol pharmacokinetics remains controversial, with some evidence supporting the association of the T allele with decreased metabolism and, consequently, lower dose requirements of propofol [OPRM1 or the CYP2B6 polymorphism on postoperative analgesic consumption, which can be explained by the very short context-sensitive half-time of remifentanil on one hand, and the very limited use of opioids and/or CYP2B6 substrates post-operatively.Our findings with respect to the effect of the five gene polymorphisms on the intra-operative remifentanil and propofol consumption were less promising, even though it is perhaps worth mentioning that all four carriers of the iewed in , and in iewed in , with inesthesia . Despitepropofol , 34, whipropofol . On the COMT 158MetMet carrier patients should display a lower opioid requirement compared to COMT 158Val carriers. Overall, however, published findings on the effects of COMT Val158Met on opioid  requirements or pain threshold, alone or in combination with OPRM1 A118G [According to previous studies of the postoperative use of morphine , 36 COMTM1 A118G , 37, 38,The HTTLPR polymorphism has been examined in association with opioid use in the past, by virtue of 5-HT involvement in the modulation of pain signaling at the spinal level, but no significant differences in daily opioid consumption were found among patients suffering from chronic pain, carrying different genotypes . With reOPRM1 A118G and CYP2B6 G516T minor allele homozygotes are obvious limitations of our study, and so could be the over-representation of women, since propofol metabolism is known to be affected by sex, among other things [Our rather small sample size and the limited number of r things . On the ABCB1 C3435T polymorphism on the postoperative perception of surgical pain which, combined with recent findings concerning heat pain perception in opioid-free patients with chronic pain, points to a significant contribution of ABCB1 efflux pump to the process of central pain management by the organism. Our data concerning the association of OPRM1 A118G and CYP2B6 G516T with intra-operative remifentanil and propofol consumption does not support their inclusion in a TCI-programming algorithm at this point.In conclusion, we have provided evidence suggestive of an effect of the Supplementary file1 (DOCX 123 KB)Below is the link to the electronic supplementary material.


The difference between Young’s moduli of the femur and the stem causes stress shielding (SS). TiNbSn (TNS) stem has a low Young’s modulus and strength with gradient functional properties during the change in elastic modulus with heat treatment. The aim of this study was to investigate the inhibitory effect of TNS stems on SS and their clinical outcomes compared to conventional stems.This study was a clinical trial. Primary THA was performed using a TNS stem from April 2016 to September 2017 for patients in the TNS group. Unilateral THA was performed using a Ti6Al4V alloy stem from January 2007 to February 2011 for patients in the control group. The TNS and Ti6Al4V stems were matched in shape. Radiographs were obtained at the 1- and 3-year follow-ups. Two surgeons independently checked the SS grade and appearance of cortical hypertrophy (CH). The Japanese Orthopaedic Association (JOA) scores before and 1 year after surgery were assessed as clinical scores.p < 0.001). The frequencies of CH in both groups were no significant difference at the 1- and 3-year follow-ups. The JOA scores of the TNS group significantly improved at 1 year after surgery and were comparable to control group.None of the patients in the TNS group had grade 3 or 4 SS. In contrast, in the control group, 24% and 40% of patients had grade 3 and 4 SS at the 1- and 3-year follow-ups, respectively. The SS grade was lower in the TNS group than in the control group at the 1- and 3-year follow-ups (The TNS stem reduced SS at 1 and 3 years after THA compared to the proximal-engaging cementless stem, although the shapes of the stems matched. The TNS stem could reduce SS, stem loosening, and periprosthetic fractures.Trial registration: Current Controlled Trials. ISRCTN21241251. https://www.isrctn.com/search?q=21241251. The date of registration was October 26, 2021. Retrospectively registered. Total hip arthroplasty (THA) is a reliable surgical treatment for hip deformity and pain that improves hip pain and quality of life. In recent years, the number of patients undergoing THA has increased worldwide, with the number of patients under 65 years of age predicted to increase in the future because young and active patients who had hip degeneration too extensive for osteotomy demanded to regain full activities , 2. AlthStress shielding (SS) affected aseptic loosening when combined with other risk factors such as polyethylene wear and low-precision installation of the prosthesis , 6. HighThe change of local strain caused by the difference in Young's moduli of bone and implant materials leads to SS . AbnormaHanada et al. developed the novel Ti-33.6Nb-4Sn (TNS) alloy, which has a low Young's modulus, the same tensile strength as Ti6Al4V, and functionally graded characteristics of an adjustable Young's modulus with heat treatment , 16. A nHowever, the reduction of SS by TNS stems compared to similarly designed Ti6Al4V stems has not been investigated. The aim of this study was to evaluate the reduced incidence of SS and the postoperative clinical score of TNS stems compared to similarly designed Ti6Al4V stems.2), uncontrolled diabetes mellitus, and infection around the hip joint. For the control group, due to the scarcity of patients undergoing THA with a similarly designed Ti6Al4V stem and the same surgical approach, we retrospectively reviewed the medical charts of a consecutive case series of patients who underwent unilateral THA with Ti6Al4V stem from January 2007 to February 2011. The inclusion criterion was a diagnosis of hip osteoarthritis or idiopathic osteonecrosis of the femoral head, and exclusion criteria were unavailable data in medical records or poor-quality radiographs.This was a multicentre, open-label, single-arm clinical trial. The Clinical Research Ethics Committee of Tohoku University Hospital approved the study protocol . The current clinical trial ID is ISRCTN21241251. Informed consent was obtained from all patients undergoing THA from April 2016 to September 2017. Patients awaiting unilateral THA were included in this trial and enrolled in the TNS group. Inclusion criteria were age over 20 years and a diagnosis of osteoarthritis, avascular necrosis, or rheumatoid arthritis. Exclusion criteria were the previous operation of the affected side of the hip , bilateral hip disorder, rheumatoid arthritis of Charnley category C (multiple joint diseases or other diseases limiting mobility) , a histoFigure All patients underwent THA with the conventional posterolateral approach . Six ortAnteroposterior radiographs of the bilateral hips and lateral radiographs of the affected hip were acquired preoperatively and immediately and 1 and 3 years postoperatively in both TNS and control groups. The incidence of SS was assessed with radiographs at 1 and 3 years postoperatively using Engh’s classification . The freThe Japanese Orthopaedic Association (JOA) scores were used to assess the clinical outcomes preoperatively and 1 year postoperatively in both groups. The JOA hip scoring system is a 100-point scale that comprises subcategories of pain (40 points), range of motion (20 points), ability to walk (20 points), and activities of daily living (20 points) .p < 0.05.All results are expressed as mean ± standard deviation. Patient characteristics of the TNS and control groups were analysed using the Wilcoxon signed-rank test. JOA scores were compared using the one-way analysis of variance with the Tukey–Kramer post hoc test . Kappa coefficients were calculated for the reproducibility of scores between examiners in the grades of the Engh's classification and CH using SPSS version 21  to assess the reliability of the measurements. Differences in the incidence of SS and CH and the frequency of SS according to Gruen zone were determined using Pearson's Chi-squared test. Statistical significance was set at We enrolled 36 women and four men in the TNS group and 22 women and three men in the control group. The mean ages at operation in the TNS and control groups were 64.2 ± 10.7 and 64.1 ± 10.6 years, respectively (Table Table p < 0.001; Table Figure The incidence of CH did not differ significantly between the TNS and control groups at the 1- or 3-year follow-up. The interobserver reliability of the CH assessment was calculated. Kappa coefficients were 1.0 at the 1- and 3-year follow-ups in both groups. The reliability of the scale was excellent.Preoperative JOA scores were 47.1 ± 10.4 and 40.2 ± 11.1 in the TNS and control groups, respectively, showing a statistically significant difference (Fig. This was the first study determining the severity of SS by comparing TNS and similarly designed Ti6Al4V stems. The TNS stem prevented SS in the short term. The clinical results of the TNS stem were acceptable compared to the metaphyseal-engaging cementless Ti6Al4V stems currently in use.SS is a mechanical phenomenon that occurs after stem implantation into the femur and is caused by multiple factors, including stem stiffness, area of surface treatment, and large stem size compared to the femur size –29, withFemoral components of THA comprise articulation, structure, and fixation, with different mechanical properties. The requisite of the structural component, which couples the articulation and fixation components, is sufficient strength to overcome peak and dynamic stresses. When a stem is manufactured from a single alloy, such as the Ti6Al4V alloy, the alloy is selected to produce the stem according to the stiffness and Young’s modulus of the part that requires the most strength. The Ti6Al4V alloy is preferable as a biomedical material for stems because of its excellent biocompatibility and corrosion resistance. In contrast, its Young’s modulus is significantly higher than that of human cortical bone, leading to an imbalance in loading between the bone and the stem. The grade of SS caused by fit-and-fill stems implanted in the control group were reported previously using Engh’s classification. Kato reported that Synergy stems were shown grade 2 of SS appeared 66% and grade 3 and 4 of SS appeared 22% at 5-year follow-up . NishinoThe low Young's modulus of the TNS alloy makes it useful as orthopaedic implants. Animal models have shown it to be a promising material for fracture treatment devices. Fracture healing is multifaceted, and besides material advantage, stem cell differentiation and proper inflammation are required for bone repair . Mouse aThis study has several limitations. First, the control group did not undergo THA during the same period as the TNS group, and two types of stems were implanted in the control group. The methods or sites of stem surface treatments did not match completely with the TNS stem. Young's modulus of stems was not measured in the control group. It was ideal that Ti6Al4V stem having the completely same shape and surface treatment of the TNS stem was implanted as control. However, this was the first trial of TNS stem in clinical use. It was an ethical problem that the Ti6Al4V stems completely matched in shape and surface treatment were implanted in the control group. We aimed to compare the stems in current use having the concept of metaphyseal-filling stems focused on stem shape. The shape of the TNS stem was categorized as metaphyseal-filling or fit-and-fill stem. The number of control group did not completely match because the control group was selected retrospectively. Second, the SS was not evaluated quantitatively, such as evaluating bone mineral density of femurs. We did not evaluate bone mineral density of femurs. SS was evaluated using Engh’s classification and Gruen zone for comparison with previous studies using radiographic analyses of control stems implanted in this study –41. ThirThe TNS stem reduced SS at 1 and 3 years after THA compared to the proximal-engaging cementless stem, although the shape of the TNS stem was matched. The TNS stem could reduce SS, stem loosening, and periprosthetic fractures. Further studies are needed to determine whether a low Young’s modulus TNS stem can reduce stress shielding and improve long-term outcomes of THA.


Various regional anesthetics have been used for postoperative analgesia for pediatric craniotomy. In this case series, we report retrospectively collected data on postoperative pain and analgesic use in 44 patients who received ultrasound-guided occipital nerve blocks in addition to intravenous analgesic agents for posterior craniotomy procedures. In the immediate post-anesthesia care unit, pain was rated as zero or well controlled in 77% of patients, with only 43% requiring intravenous or demand patient-controlled analgesia opioids. There were no block-related complications. Occipital nerve blocks may constitute a safe and effective component of multimodal analgesia in this population. Greater occipital nerve blocks are well described and frequently used in the management of pediatric headache disorders, including those related to prior surgery and trauma ,2. DescrHere, we report postoperative pain and opioid use in 44 patients who received intraoperative greater occipital nerve blocks for posterior cranial surgery.The study was deemed exempt from review by the Ann and Robert H. Lurie Children’s Hospital of Chicago Institutional Review Board (IRB 2020-3969) as a quality improvement initiative using deidentified, retrospective patient data and granted a full waiver of Health Insurance Portability and Accountability Act (HIPAA) authorization. Informed consent and site marking for greater occipital nerve blocks were performed with a parent or legal guardian per institutional standards. Between August 2016 and October 2019, 44 patients received greater occipital nerve blocks for procedures involving posterior cranial incisions for decompression or resection of tumors, cysts, or cavernous malformations. An anesthesiologist obtained informed consent for the block procedure and performed regional anesthesia site-marking with each patient’s parent or guardian in the preoperative area.Greater occipital nerve blocks were performed following induction of anesthesia, prone positioning, and sterile preparation. To perform the blocks, a linear ultrasound probe was used to locate the C2 spinous process, and the probe moved laterally and rotated  to find Following surgery, patients were placed supine and extubated prior to transfer to the recovery area. All patients were initiated on patient-controlled analgesia (PCA) with morphine or hydromorphone on a demand-only basis without continuous basal infusion. Pain scores were recorded using the numeric rating scale (NRS), visual analog scale (VAS), revised Faces, Legs, Activity, Cry, Consolability (rFLACC) scale, or FACES scale. We defined pain scores of 0, 1–3, 4–7, and 8–10 as no pain, well-controlled, poorly controlled, and uncontrolled pain, respectively. Patients were transitioned to oral opioids on postoperative day 2, and adjuncts such as non-steroidal anti-inflammatory drugs (NSAIDs) and acetaminophen were added when appropriate by the surgical team. Data on PCA use, pain scores, and adjunct use were collected retrospectively and analyzed.n = 25, 57%) and brain tumor . Blocks were performed 215 min (range: 161–262) prior to emergence with 0.18 (interquartile range: 0.13–0.26) mL/kg of 0.2% ropivacaine under ultrasound guidance, with no related untoward events at any point. Additional patient demographic information, intraoperative medications, and block details are listed in Our analysis included 44 patients, 18 males and 26 females, who received occipital nerve blocks for posterior fossa procedures. The mean age was 12 years (range: 4–15). The most common indications for surgery were Chiari malformation type I (In the post anesthesia care unit (PACU), pain was rated as no pain or well-controlled pain in 77% of patients, with 43% receiving intravenous or demand PCA opioids in the earliest period . The medFollowing surgery, no long-term complications related to blocks were noted at subsequent office visits. One patient reported neck pain without headaches for one week. Another patient reported migraines one week prior to outpatient follow up that resolved without intervention.Pain control following craniotomy is of significant clinical concern and has been historically undertreated . StudiesScalp blocks offer a potential means for pain control after a craniotomy and have been well studied. A recent randomized, placebo-controlled study on pediatric patients undergoing a craniotomy for brain tumor demonstrated improved postoperative pain and intraoperative hemodynamic stability with scalp blocks using 0.2% ropivacaine . A recenIn contrast to scalp blocks, greater occipital nerve blockade may be used for medial posterior fossa surgeries but is of limited value for other craniotomy incisions. However, using a more proximal approach at the C2 level may result in additional blockade of other nearby nerves, such as the lesser occipital and third occipital nerves, which are closer together at this level . The bloA recent randomized, controlled trial by Nassar et al. from Egypt found greater occipital nerve blocks to be associated with greater duration of postoperative analgesia in a group of 17 patients with American Society of Anesthesiology (ASA) status 1 or 2 undergoing posterior fossa craniotomy compared with 18 controls . In thisThis study’s primary limitations are its relatively small sample size and its lack of a control group, making it difficult to determine the magnitude which the greater occipital blocks reduced opioid use and pain scores. Subjective pain scores were collected from the electronic medical record retrospectively, which introduces the possibility of variation in documentation and assessment quality. As has been described previously, while the NRS, VAS, rFLACC, and FACES scores are well validated, it may still be challenging to accurately assess pain in this population . VariablIn summary, we present a large case series of greater occipital nerve blocks for postoperative pain control in posterior fossa surgery. We observed no adverse events related to the blocks and found them to be easy to learn and perform. A prospective, randomized, placebo-controlled study to quantify reductions in opioid use and pain scores attributable to greater occipital blockade is necessary.


Myofascial pain is the most common cause of chronic pain in the masticatory region and can be assessed through clinical analysis and muscle palpation. Generally, it appears with headache and orofacial pain associated with sensitive points (trigger points) due to the excessive contraction of the masticatory muscle fibers. The study aims to evaluate how a correct treatment of myofascial pain can improve the life quality of affected patients. In this case series, 300 patients with myofascial pain were divided into two groups: 150 with intra- and extra-articular disorders and 150 with only extra-articular disorder. Each group included 75 males and 75 females. All the patients were treated with gnathological therapy through passive aligners and biofeedback exercises for four months. They underwent pain assessment  before, during, and after the treatment, as well as nuclear magnetic resonance of the temporomandibular joint before and after the gnathological treatment. The treatment considerably reduced the pain in all patients, without drugs, in four months according to the visual analogue scales and the palpation test. The temporomandibular magnetic resonance in each patient was similar before and after the gnathological treatment. The improvement in pain did not depend on a change in the relationship between the articular condyle and the disc.  Temporomandibular disorders (TMDs) are a group of musculoskeletal and neuromuscular conditions involving the temporomandibular joint complex and the surrounding musculature and osseous components. TMDs affect up to 15% of adults, with a peak incidence in patients between 20 and 40 years of age. In the context of the multifactorial etiology of TMDs, the importance of the psychological component has been demonstrated.Chronic stress alters the body’s physiological processes, causing inflammation, oxidative stress, and changes in hormones and immune function, increasing the risk of developing chronic diseases. For example, a correlation between TMDs and post-traumatic disorder in war veterans has also been found; war is one of the primary sources of exposure to stress . Some stA systematic review demonstrated the high prevalence of depressive disorders in patients with TMDs . A correTMDs are classified as intra-articular and extra-articular diseases. Intra-articular TMDs are congenital, developmental, or degenerative disorders in which the relationship between the articular disc, the mandibular condyle, and the glenoid fossa is impaired. Extra-articular TMDs include disorders involving the masticatory muscles such as local myalgia, myofascial pain disorder, myofibrotic contracture, myositis, and myospasm . The eti2 inside the connective tissue) than the muscle (227.6 fibers/area mm2). Moreover, most of the nerves were nociceptors [This painful condition is characterized by myofascial trigger points (MTrPs) , which aiceptors . Patholoiceptors . Studies also reported that tension-type headaches (TTHs) and migraines are associated with referred pain from TrPs in several muscular areas such as the suboccipital, upper trapezius, sternocleidomastoid, temporalis, or superior oblique muscles. Referred pain caused by active TrPs simulates the pain areas detected during head pain episodes in these primary headaches ,20,21. OPrimary headache disorders are unrelated to an underlying medical condition and are classified into four groups: migraines, tension-type headaches, trigeminal autonomic cephalalgias, and other primary headaches. Secondary headache disorders are related to an underlying medical condition.Migraine is the most debilitating primary headache disorder and affects 12% of the population. It is characterized by several symptoms, with headaches as the hallmark. It can be treated acutely with analgesics, nonsteroidal anti-inflammatory drugs, triptans, gepants, and lasmiditan . MigrainA migraine attack can last 4–72 h and consists of four overlapping stages.(a)Premonitory phase: This happens hours or days before the onset of the headache, with non-painful symptoms such as frequent yawning, difficulty concentrating, fatigue, and thirst.(b)Aura: This is a transient focal neurological symptom that can happen before or during some of the headaches. Visual aura is the most frequent type (90%), followed by sensory (30–54%), and language auras (31%).(c)Headache: The result of the activation of the trigeminal sensory pathways, which generates the throbbing pain. It interferes with daily activities and typically gets worse with head movement. It is usually associated with nausea, vomiting, and aversion to light (photophobia) and sound (phonophobia).(d)Postdrome: Characterized by tiredness, drowsiness, difficulty concentrating, and hypersensitivity to noise .Myofascial trigger points are prevalent in migraine and tension-type headaches, but their role in the pathophysiology of each disorder and to what degree is unclarified .Myofascial pain in masticatory muscles is associated with parafunctional habits such as teeth clenching and grinding and emotional factors such as distress. Parafunctional patterns during the day and sleep bruxism induce the intensification of muscle tension connected to myofascial pain . The musThe presence of myofascial trigger points and associated orofacial and referred pain diagnose myofascial pain syndrome. The trigger points can be detected by palpation of the muscles, which consists of palpating the muscle perpendicular to the direction of the muscle fibers . The palFurthermore, ultrasound imaging makes assessing the muscles and fasciae of the head and neck region activity and the trigger point areas possible. Ultrasound permits the evaluation of the ability of the muscles to contract and identifies functional asymmetry that could become symptomatic . UltrasoThis study aimed to evaluate reductions in head and orofacial pain caused by MTrPs associated with unconscious teeth clenching. Patients were treated with passive aligners and biofeedback exercises to teach them not to clench their teeth . The treDue to this important correlation between chronic pain disorders and the psychosomatic state of patients, we were very interested in alternative and non-pharmacological management of the symptoms of myofascial pain syndrome.An adequate, non-pharmacological, gnathological therapy leads to the remission of orofacial pain and active trigger points ,35.This case series was conducted in the Oral Sciences Department of the University of Chieti G. D’Annunzio. The study protocol was designed per the European Union Good Practice Rules and the Helsinki Declaration. Each patient provided written informed consent to participate in this study. Ethics approval (number 23) was obtained by the hospital’s Independent Ethics Committee of Chieti. The study considered diagnosing myofascial pain with referral headaches according to DC/TDM and ICHD-3 beta criteria. All 300 selected patients underwent a quantitative pain assessment through a visual analogue scale (VAS) and palpation test before and during treatment and magnetic resonance imaging of the temporomandibular joint (TMJ MRI) before and after the gnathological treatment. The initial TMJ MRI was required to collocate patients in the right groups; the final TMJ MRI was needed to assess the unaltered relationship between the disc and condyle.The study lasted for three years (2020–2022): eighteen months to recruit the patients, twelve months for the follow-up, and six months for the data processing. The patients were treated for four months. Sample size 358 patients were eligible for the study . 42 declThe sample included 300 patients with unconscious teeth clenching and myofascial pain syndrome. 150 patients with extra-articular TMDs were included in the first group, whereas 150 patients with extra and intraarticular TMDs were included in the second group. Each group comprised 75 men and 75 women. Inclusion Criteria(1)Patients between 18 and 55 years of age.(2)Diagnosis of myofascial pain in the masticatory muscles.(3)Pain, including headache, in the last 30 days since the stated sensitivity (new DC/TMD)(4)Average pain severity of four on a ten-point scale for at least 1 h daily.Exclusion Criteria(1)Pregnancy.(2)Psychiatric disorder or current use of psychiatric medications.(3)The presence of the cause of the chronic pain disorder.(4)Family history of arthritis or gout.(5)Current use of non-steroidal anti-inflammatory drugs, paracetamol, or opioids.MeasurementsVAS: visual analogue scale. A graphic representation of a patient’s face where they had to highlight painful areas, specifying the intensity (from 0 = No Pain to 10 = Maximum Pain) and occurrence of the disturbance . Each patient completed the VAS before and after treatment and each month in the follow-up appointments. Every month, the same operator visited each patient.PALPATION: The aim was to find trigger points in masticatory muscles , which, once stimulated, produce or increase orofacial pain and referred headache. The same operator performed the palpation on all patients every month. The operator manually exerted a pressure of 1 kg bilaterally for 5 s on the masseter, temporal, pterygoid, sternocleidomastoid, and digastric masticatory muscles. -0: absence of pain.-1: mild pain or apparent discomfort.-2: moderate pain or discomfort.-3: severe pain .The pain was classified by the patient on a scale from zero to three: Each patient underwent a palpation test before and after treatment and each month in the follow-up appointments. Every month, the same operator performed the palpation test. MRI TMJ: MRI evaluated the integrity of the temporomandibular joint. It was used to diagnose intra-articular or extra-articular disorders before treatment, to localize patients in the correct group, and to assess changes in the condyle–disc relationship after treatment. Each patient underwent a TMJ MRI with open-mouth and closed-mouth postures before and after the treatment. Treatment protocolThe treatment protocol used two passive Essix splints (lower and upper). To obtain the greatest possible comfort for the patient, the splints were made of polycarbonate and customized in the mouth to avoid irritation or damage to the soft tissues. The thickness of the splints was <0.7 mm. The patients wore the lower passive aligner splint (LPAS) during the daytime and the upper passive aligner splint (UPAS) at night. The splint was removed only at mealtimes and during oral hygiene, and the two splints were never in the mouth simultaneously.While wearing the LPAS, the patients performed a biofeedback exercise for two minutes daily  over the study duration to enable us to manage the masticatory muscle activity.To avoid bias during the biofeedback exercise, the patients had to maintain an upright or lying position without crossing their legs or arms. Traditionally, biofeedback is presented to the patient and the clinician via visual displays and acoustic or vibrotactile feedback . In our The exercise consisted of four steps . The total contraction on the masseters and the teeth clenching characterized the first step. The patients had to visualize the maximum contraction of the muscles as a fully inflated tennis ball, with the help of a light touch of the cheeks with the forefinger.In the second step, the patients had to clench their teeth, partially contracting the masseter (on each side) and associating a light touch with the forefinger. A semi-deflated tennis ball was visualized this time .During the third step, the patients fully relaxed their jaw (opened about 1 mm). They applied a light touch with the forefinger to the fully relaxed masseter, visualizing the muscle’s volume as a deflated tennis ball.In the last step, the patients touched the top of the palatine vault with the tip of their tongue for five seconds .The duration of the treatment (and consequently of the performance of the biofeedback exercise) was four months. Then, a new assessment was made using the VAS and palpation of the pertinent muscles, and TMJ MRI was repeated to evaluate the treatment effect and outcome.The patients recorded pain diaries during the study period to supervise compliance and examine and monitor symptom development . Patients were followed up after one year, and only six of them showed relapses with mild symptoms . Study ProtocolThe subject selection required the diagnosis of myofascial pain syndrome based on a standardized and complete clinical examination, which fulfilled the Research Diagnostic Criteria (RDC TMDs) . After recruitment, they underwent a TMJ MRI to assess the intra-articular TMJ condition. The study included 300 patients with myofascial pain matched for sex, 150 with intra-articular and extra-articular TMDs and 150 with extra-articular TMDs, classified by the TMJ MRI.In the study’s first phase, the patients underwent the palpation test and visual analogue scale to assess, measure, and locate the pain. In the study’s second phase, the patients were treated with the gnathological therapy previously described for four months. All patients underwent follow-up appointments once a month, in which they underwent the VAS and palpation test again with the same operator every time. After four months, TMJ MRIs with open-mouth and closed-mouth postures were performed again. Statistical methodsAll statistical analysis was performed using SPSS 26.0  and evaluated at a two-tailed alpha level of 0.05. The sample population was assessed to determine the deviation ratio for women to men from the expected 1:1 (Fisher’s exact test) and differences in the distribution of VAS scores (Pearson’s chi-squared). The effect of the treatment protocol on modifying the parameters was assessed using a Wilcoxon signed ranks test. Correlations between the modification of VAS with the baseline and changes in palpation measurements were evaluated using Spearman’s rho. All patients were affected by orofacial pain and headache but no migraine. Nine out of the three hundred included patients were excluded from the study because they did not follow the operator’s instructions about using splints and biofeedback exercises. After treatment, the primary outcome was pain reduction, assessed using the VAS and palpation test after four months. Patients were re-examined after one year; only six showed relapses with mild orofacial pain. Nevertheless, these patients did not require any medications. We observed that pain symptomatology decreased in all patients by comparing the baseline values (T1) to post-treatment values (T2). The improvements were unrelated to age and gender but related to symptom intensity and chronicity at T1. The characteristics of the study group are reported in All patients completed the treatment protocol using gnathological therapy consisting of passive aligners  and biofThe statistical results are reported in p < 0.001, Wilcoxon signed ranks test). The sample population did not differ from the expected 1:1 ratio of women to men, and the distribution of VAS scores with age did not differ between the sexes. Treatment significantly modified the VAS and palpation scores (p = 0.001) and correlated with the improvement in the sternocleidomastoid palpation score (p = 0.016). There was a trend toward statistical significance with the pterygoid palpation score (p = 0.092). The modifications in palpation scores were all highly correlated, with a range of p < 0.001 (to p = 0.021), except for temporal–pterygoid, masseter–pterygoid, and pterygoid–digastric correlations. The modification of VAS scores was highly correlated (positively) with the change in the masseter palpation score . Initial palpitation scores did not correlate with modifications in the VAS score, except for the pterygoid palpation score (p = 0.040).When dividing the sample population into women and men separately, only the initial temporal palpation scores negatively correlated with the modification of the VAS score  in the 150 patients with the extra-articular disorders and the 150 patients with the intra-ed extra-articular disorder was assessed by comparing the baseline (T1) and post-treatment (T2) pain extents, and intensity of pain during palpation test decreased uniformly. Again, the improvements were not related to age and gender but to symptom intensity and chronicity at T1. This study reports the impact of gnathological therapies with passive aligners  and biofMyofascial pain can be treated through invasive or non-invasive procedures. Non-invasive procedures include spray-and-stretch, transcutaneous electrical stimulation, physical therapy, and massage. Among them, fascial manipulation was shown to reduce pain and is the gold standard in orofacial pain treatment . InvasivThe biofeedback technique is a method to teach patients to recognize, correct, and prevent the physiological alterations underlying various pathological conditions, with their consequent reduction or elimination. Biofeedback approaches to headache therapy fall into two broad categories: general biofeedback techniques and techniques more directly related to the pathophysiology underlying the onset of the headache. Several meta-analyses have evaluated the use of available biofeedback-assisted relaxation techniques for headaches. These reviews indicate that various biofeedback techniques are effective for migraine and tension-type headaches . BiofeedAlthough some studies have demonstrated the effectiveness of biofeedback in neuromuscular system physical rehabilitation , our proThis study included 300 pts (150 men and 150 women), aged between 18 and 55 years, who showed orofacial pain , masticatory muscle trigger points, and mandible movement restriction. None of the 300 patients experienced migraines and none had a family history of arthritis or gout. After the treatment, we noticed a significant  decreaseThe treatment protocol does not change the intra-articular interaction between the disc and condyle, as revealed by the MR analysis of the TMJ, thus limiting its action to ameliorating the symptoms . HoweverFinally, our findings demonstrate that this therapeutical setup efficiently reduces  myofasciWe consider these results very important, especially because they occurred after the COVID-19 pandemic, during which there has been a serious increase in stress and, consequently, in the prevalence of TMDs. Furthermore, this data is very interesting as it enables chronic pain management without using drugs. Because the use of medications during the pandemic has been chaotic and controversial, patients have greatly appreciated the resolution of pain without a medication prescription, improving their quality of life and mood.No improvements have been observed in patients with intra-articular disorder regarding disc dislocation. Pain relief does not depend on a change in intra-articular condition.From our perspective, the importance of this research lies in the fact that orofacial pain was treated with a conservative non-medical treatment that requires only four months. The patients were re-examined after one year, and only six showed a mild relapse, which did not require any drugs.The limit of this study is the wide range of ages. Nevertheless, we think it can be helpful to those clinicians who want to treat orofacial pain and referred headaches caused by myofascial pain syndrome of the masticatory muscles without medications and with a low relapse rate after one year.


Tennis elbow or lateral epicondylitis is a common complaint involving about a 3-5% cases in a community. Non-surgical treatment is effective in 80% of cases. Recent studies have shown the effect of autologous blood on improving the pain and function of affected patients. The present study aimed to compare the effectiveness of steroid and autologous blood local injection in controlling pain and disability in the short and long term.The present study was a clinical trial conducted in Shahid Beheshti Hospital of Babol. A total of 60 patients were divided into 3 groups; A group injected at the site of lateral epicondylitis with steroid (methylprednisolone acetate-40mg) and another group with autologous blood (2ml of venous blood), and the other group used a brace for 3 weeks. Patients were followed-up for 15, 30, and 90 days, and the PRTEE assessment questionnaire assessed their pain and disability.On the 15th day, there was no statistically significant difference in pain and function in the three groups, although the injectable groups were relatively more effective. On the 30th day (p=0.001), the local corticosteroid was significantly better than the autologous blood group, while on the 90th day (p<0.001), autologous blood was significantly better than the local corticosteroid. The average day, in which 25% improvement was gained, was lower in the autologous blood transfusion group.Regarding the long-term effect of autologous blood on corticosteroid injections, it was recommended as a lateral epicondylitis treatment. Lateral epicondylitis is a common elbow disorder mainly due to repeated movements of wrists and fingers and stress in the origins of extensor muscles . The incMost non-surgical cases are supposed to suppress inflammation that does not occur in the tendinosis. Oral and injectable steroids and ice massage are signs of this approach . A betteAn evaluation criterion was introduced in 2005 as the patient-rated tennis elbow assessment (PRTEE) that was responded to by patients or residents . TherefoIn the present clinical trial study, patients with lateral epicondylitis referring to Shahid Beheshti Hospital of Babol during 2017-2018 were considered the statistical population. Using studies and confirmation of statistical counseling and according to the probability of 25% drop in each group, the sample size was supposed to be 20 and 60 subjects. The simple sampling method was performed. Inclusion criteria: Patients with tennis elbow referring to Shahid Beheshti Hospital. Exclusion criteria: Patients with a history of long-term corticosteroid consumption (more than three consecutive months), rheumatoid arthritis, bilateral symptoms and deformity of elbow, patients with a history of previous injection, trauma and elbow fractures, and elbow surgery. Patients were randomly divided into three groups . Two milliliters of autologous blood of the first group were taken from the upper limb veins, and it is then mixed with 1 ml of 2% lidocaine solution and injected into lateral epicondylitis site under the Extensor Carpi Radialis Longus. In the second group, 40 mg of methylprednisolone acetate was mixed with 1 ml of 2% lidocaine and injected into the same place with the first group in the Extensor Carpi Radialis Brevis Longus. In the third group (control group), the tennis ball was alone used for 3 weeks after starting the treatment. All three groups of patients learned how to use appropriate tools and hand positions, and tennis elbow braces were given to patients in the first three weeks. All participants were evaluated on day zero (before the intervention), 15, 30, and 90. Evaluation and follow-up were done by Patient-Rated Tennis Elbow Assessment (PRTEE) questionnaires responded to patients. PRTEE questionnaire included two series of questions about patient pain and functions. Five pain questions scored from pain with zero scores to the worst possible pain with a score of ten. There were ten function questions with a score of zero for activity without any problem in ten for inability to work. The total pain and function scores were separately examined in three groups, and then their summed scores were considered as patients’ total scores. Data analysis was done using SPSSV22 by ANOVA, chi-square test, and analysis methods such as Kaplan–Meier method, log-rank test, and Cox-Regression with a confidence level and significance of p<0.05. (IRCT20180422039382N2 / IR.MUBABOL.HRI.REC.1397.074)In the present study, 60 patients were divided into three treatment groups. A group was braced for only three weeks, another group was braced for three weeks and received corticosteroid injection, and the other group was braced and received an autologous blood injection. Among the patients who have received blood injections, 4 patients (2 patients due to increased pain and corticosteroid injections) stopped the follow-up. Among the second group of patients treated with corticosteroids, three patients discontinued follow-up (2 patients due to relapses and corticosteroid re-injection). Among patients, who only used braces, 7 ones continued follow-up (5 patients due to relapses of pain and function and the use of other therapies). Therefore, 17 patients in the corticosteroid group, 16 in the blood injection group, and 13 in the brace group completed the research. In the present study, 34 (56.6%) women and 26 (43.3%) men participated with a women/men ratio of 1.3:1. The patients’ age range was 24-64 years. Twenty-one (45%) men and 25 (55%) women completed the study. Two cases of ecchymosis were seen in patients with corticosteroid injections and 3 cases of ecchymosis in patients with autologous blood injections. According to Statistical ANOVA was used to examine and compare the impact of three therapies on the patient’s pain, and three therapeutic methods were compared. Based on the analysis of variance of patients’ pain scores, it was concluded that three therapeutic methods were not significantly different according to p-values during the treatment days of 0 and 15, but effects of treatments were significantly different on days 30-90 of follow-up. It was more effective in corticosteroids than other treatments, and patients had lower mean pain scores. However, the treatment with autologous blood was more effective, and patients had lower mean pain scores on day 90. Kaplan–Meier method was used to measure the survival rate for remission, considering the remission rate of 25%. According to the studied meantime of painful recovery, Kaplan–Meier method and log-rank test indicated that the treatment with autologous blood reduced pain by 25% on 31.5 ± 7.7 days with a confidence interval of 16.41-46.58 days. In addition, the mean pain relief in brace treatment was 71.25 ± 7.26 days with a confidence interval of 57.02 to 85.48 days. In the corticosteroid-treated group, the mean day of pain relief was 8.34 ± 48.75 days with a confidence interval of 32.40 to 65.10 days, and results of this test indicated significant differences between the three groups in terms of mean day of pain relief. (p <0.001) According to Kaplan–Meier method, for investigating the mean day of function relief, the treatment with autologous blood reduced the function score by 25% on day 33.00± 7.5 with a confidence interval of 18.29 to 47.71 days. In addition, it was 78.75 ± 5.90 days with a confidence interval of 67.01 to 90.49 days for evaluating the mean day of improvement by bracing. In the corticosteroid-treated group, the mean recovery day was 8.23± 56.73 with a confidence interval of 72.86 to 40.59. The results indicated significant differences between the three groups regarding improved function (p <0.001). Results in In the present study, 60 patients with lateral epicondylitis were evaluated, of which 26 (43.3%) were males, and 34 (56.7%) were females, with a sex ratio of 1.3:1. The mean age of patients was 48.18 years, with the range of 24-66 years. A topical corticosteroid is a common approach to the treatment of musculoskeletal disorders. This is a simple and inexpensive way to reduce pain and other symptoms associated with inflammation. Several biological hypotheses have been proposed to approve the effects of corticosteroids on pain control, such as prostaglandin suppression, connective tissue modification, extracellular matrix, adjustment of pain receptors and chemical intermediates, and correction of relationships between tendon structures and para-tendinosis tissues . Despite the non-approval of the hypotheses mentioned above, the effectiveness of corticosteroids is clinically shown in pain relief. In fact, the evidence suggests that corticosteroids are more useful than other treatments for short-term pain relief . HoweverIn the past, it was found that the patient status was recovered when the minor trauma emerged on the lateral epicondylitis site. After releasing the tendon insertion in lateral epicondylitis, Wadsworth found good results by manipulating the package under anesthesia . BaumgarOur studies indicated that patients’ pain scores decreased and patients’ function scores improved in all three groups of corticosteroids, autologous blood, and brace injection on the 15th day of follow-up. According to statistical analyses, there were no significant differences between mentioned treatments, and all of them equally affected the pain relief and function improvement. Sirico et al. found a relative priority in corticosteroid to autologous blood in recording points’ VAS scores in a 2-week follow-up . On the 30th day of follow-up, decreased pain and function scores (function improvement) were seen in both groups, but this reduction was better in the corticosteroid group than the blood injection group and was statistically significant (p< 0.05). This finding was consistent with studies by Roy et al., but Kazemi et al. found the same effect on corticosteroid and autologous blood injection at four weeks of follow-up, but autologous blood seemed to be more effective , 15. JanOn the 90th day of follow-up, there was a decrease in pain and function scores (function improvement) in both groups compared to the injection day. In the corticosteroid injection group, the mean score of PRTEE had an increase of about 3 scores compared to the follow-up day of the 30th day, indicating the relative relapse of pain in patients of this group. However, in the group with autologous blood injection, the pain relief was seen compared to the 30th day of follow-up, indicating the slower trend of autologous blood therapy, but its long-term effect was more obvious than corticosteroid. Analysis of data was statistically significant (p< 0.05). Keratakanavar et al. found significant differences between two corticosteroids and autologous blood groups on the 12th week, and both scores of VAS and the Nisrschl stage were lower in the autologous blood group . Kazemi A prospective randomized study reported a significant reduction in pain 6 weeks after topical corticosteroid injection in 58 patients with lateral epicondylitis. However, the relapse rate was higher after 3 months . In anotIn a study for determination of mean day when patients were obtained 25% of the recovery in different treatment groups, the autologous blood injection group sooner achieved 25% of recovery than the other treatment groups reflecting the more effective autologous blood injection than corticosteroid and brace. The difference was statistically significant. Arik et al. found a complete recovery rate of 95% in autologous blood injection during 3 months, while it was 62.5% in the corticosteroid group .According to this study, it was concluded that the topical corticosteroid injection had a sooner analgesic effect and a greater effect than autologous blood in the short-term treatment for up to a month, but the relapse (increased pain score and loss of function) was seen in patients up to three months. The autologous blood had a slower effect than topical corticosteroid injection, but it had a lasting effect than topical corticosteroid injection and reduced the patient need for repeated injection in the long term.