Lower back pain is a common issue, but little is known about the prevalence of pain in patients with liver cirrhosis during hospitalisation. Therefore, the objective of this study was to determine lower back pain in patients with liver cirrhosis.n = 79; men n = 55; women n = 24; mean age = 55.79 ± 12.52 years). The hospitalised patients were mobile. The presence and intensity of pain were assessed in the lumbar spine during hospitalisation. The presence of pain was assessed using the visual analogue pain scale (0–10). The range of motion of the lower spine was assessed using the Schober and Stibor tests. Frailty was measured by Liver Frailty Index (LFI). The condition of liver disease was evaluated using The Model For the End-Stage Liver Disease (MELD) and Child–Pugh score (CPS) and ascites classification. Student’s t test and Mann–Whitney test were used for analysis of the difference of group. Analysis of variance (ANOVA) with the Tukey post hoc test was used to test differences between categories of liver frailty index. The Kruskal–Wallis test was used to test pain distribution. Statistical significance was determined at the α-0.05 significance level.The sample consisted of patients with liver cirrhosis (n = 11), and the mean intensity of pain according to the visual analogue scale was 3.73 (± 1.90). Lower back pain was present in patients with ascites  and without ascites . The prevalence of lower back pain was not statistically significant between patients with and without ascites . The base of Schober’s assessment mean score was 3.74 cm (± 1.81), and based on Stibor’s assessment mean score was 5.84 cm (± 2.23).The prevalence of pain in patients with liver cirrhosis was 13.92% (Lower back pain in patients with liver cirrhosis is a problem that requires attention. Restricted spinal mobility has been reported in patients with back pain, according to Stibor, compared to patients without pain. There was no difference in the incidence of pain in patients with and without ascites. Liver cirrhosis is the final stage of chronic liver disease  with 0 meaning no pain and 10 meaning unbearable pain . As a paSpine dynamics were examined using the Schober and Stibor tests. All examinations were performed by an investigator, a senior consultant MD, with experience in physiotherapy of patients with liver cirrhosis.https://liverfrailtyindex.ucsf.edu/) [The Liver Frailty Index is a core diagnostic modality of the guideline-recommended toolkit for physical frailty . It is csf.edu/) . The basOriginally, the MELD score was developed to predict prognosis in a particular clinical setting, but, due to its applicability, objectivity, and prediction power, it has gained acceptance as a predictor of survival in cirrhosis in general , 31. TheThis score, developed some four decades prior to MELD, aimed at the same goal – predicting survival in cirrhosis . In contThis classical test is designed to determine a range of flexion of the lumbar spine. The result is obtained as a detraction of two measurements, both starting at a level of the L5 spinous process. The first step is to draw a horizontal line that crosses the spine 10 cm proximal to the index Fig. . The accThe so-called Stibor’s distance examines the unfolding of both the lumbar and thoracic spine’s unfolding during maximal forward flexion. To this end, the second line is set at the level of the C7 spinal process, while the index point is the same as in Schober’s test. The measurements are identical to Schober’s test.2 overall, 27.51 (± 5.42) kg/m2 in males, and 25.11 (± 6.05) kg/m2 in females.Our study included 79 patients , female n-24 (30.3%). Hospitalized patients were mobile. Median age of for both groups was 55.79 (± 12.52) years. The median body mass index (BMI) was 26.78 (± 5.65) kg/mStatistical analysis All baseline characteristics were recorded in MS Excel 2016®. Descriptive statistics and confirmation of differences between the values obtained were performed in XLSTAT®. The normality of the data was confirmed by the Shapiro–Wilk. To verify the statistical significance of the difference, two sample Student’s t-test and Mann–Whitney test were used. Mann–Whitney U test was utilized in non-parametric, abnormal distribution independent groups. Student’s t test was used while using normal distribution was present. Analysis of variance (ANOVA) with the Tukey post hoc test was used to test differences between categories of liver frailty index. The Kruskal–Wallis test was used to test pain distribution. Statistical significance was determined at the α-0.05 significance level.In our study, 79 enrolled patients had a mean age of 55.79 ± 12.52), and there were 55 males (69.7%) and 24 females 30.3%). Of the patients, 42 had cirrhosis caused by ALD (53.2%), and the baseline MELD was 17.38 points (± 6.34) Table 2.52, and0.3%. Of p = 0.424). The Pain Intensity Score by VAS was mild 3.73 (± 1.90) points . Ascites were present in 44 patients (55.70%). LBP was present in 7 patients (15.91%) with ascites and in four patients (11.43%) without ascites (p = 0.426). The pain intensity scores in patients with and without ascites were 3.43 (± 2.15) and 4.25 (± 1.50), respectively (p = 0.1638).Eleven of 79 patients (13.9%) reported LBP according to the study criteria Table . Their mp = 0.1637). The mean Stibor test distance was 5.84 cm (± 2.23) in both groups. A significant difference was found between patients with LBP and those without LBP according to the Stibor test (p = 0.028). Spine mobility by Schober and Stibor tests was decreased in frail patients (Tables The mean Schober’s distance was 3.74 cm (± 1.81) in both groups and did not differ between patients with and without ascites  with LBP were identified. Treatment of pain in patients opens the door to the perception of an underexplored area with the potential to affect the outcome of cirrhosis. Although derived from a cohort size and of a relatively low VAS intensity (3.73 ± 1.90), a long-term LBP represents a serious threat to mobility, muscle mass, and function, as well as the quality of life of our patients. These factors can accumulate and, over time, lead to a bad outcome in terms of dropping out of the waiting list for a liver transplant, a worse outcome of LT, and mortality. Identifying a new association of these clinical factors with pain would have the potential to focus more / personalised attention on physiotherapy. Therefore, this could lead to improved quality of life, adherence to physiotherapy advice, and eventually increased survival to liver transplant, as well as overall survival .In contrast to our expectations, no increased prevalence of LBP was found in patients with ascites. We based our assumption on the influence of the static and dynamic aspects of spine physiology. The psoas muscles also supported our hypothesis of an increase in LBP in ascitic cirrhosis because, on the one hand, they are the main supporting apparatus, and, on the other hand, they are the primary site of sarcopenia in cirrhosis , 35. SarPatients with more advanced liver disease have an increased prevalence of pain , which iThe association of pain with Stibor and Schober tests can be formulated as the more limited the movement of the spine, the more pain patients experience. This is important since the performance of Stibor and Schober is feasible and safe in real-life clinical practice, and when testing positive (limited range), patients can be motivated by more advice to increase their flexibility.frailty – spine – pain in the current approach based on the pathway frailty – muscle – prognosis. It could be that such modified physical therapy will result in a better quality of life, adherence, and prognosis for patients with cirrhosis  [Physical performance has also been found to be associated with altered spine dynamics by other authors . Furtherascites) . Based oCompared to other diseases, the incidence of LBP was low in patients with liver cirrhosis. Patients with COPD suffer from nonspecific LBP, which varies from 41.2% to 69% , 43 in cIn general, patients with liver cirrhosis are less physically active than patients without liver cirrhosis. Hypoactivity is considered one of the most important factors in the development of LBP. The purpose of the meta-analysis by Alzahrani et al.  was to eTreating LBP in patients with liver cirrhosis can be difficult. In most cases, conservative therapies are used to treat LBP . RehabilTherefore, before fully appreciating the neutral association between ascites and LBP, more data are needed from other studies with more patients. If neutrality was confirmed, this could be explained by the decreased mobility of patients with ascites, where pain is less likely to be elicited.In our study, 7 patients took analgesics for other causes, which could have affected the incidence and intensity of pain in patients. The use of analgesics in patients with liver cirrhosis is common . AccordiAcute spinal pain was followed during hospitalisation in patients with liver cirrhosis who remained present for one week. However, if we had followed the incidence in the past, the incidence in patients would probably be much higher.Another limitation was the size of the group, despite the larger group of patients, with a larger examination, it is possible to see a higher or lower incidence of back pain in patients with liver cirrhosis.LBP in patients with liver cirrhosis is a problem that requires attention. However, our study did not report a higher incidence of LBP. Restricted spinal mobility has been reported in patients with back pain in Stibor test compared to patients without pain. There was no difference in the incidence of pain in patients with ascites and without ascites.


This study explored the impact of different doeses of doxorubicin in CT-guided transvertebral foraminal injections for postherpetic neuralgia (PHN) treatment and the impact of 0.5% doxorubicin treatment on patients with different disease courses and lesion locations.This retrospective study included 291 patients with PHN who received CT-guided doxorubicin injection at West China Hospital between April 2014 and February 2020.p < 0.001) and a significant lower score on the BPI at 6 and 12 months than the 0.33% doxorubicin group . Stratified analysis of 0.5% doxorubicin demonstrated a significant reduction in VAS score at 1 week, 3 months, 6 months, and 12 months after treatment compared to baseline  and significant improvements in BPI score after treatment compared to baseline (p < 0.05). The VAS score of the chest group was significant higher than facial, neck and upper limbs and abdomen groupsin groups 1 week after surgery . Various aspects of quality of life, including daily life, enjoyment of life, sleep, relationships, work, walking ability, and emotions, significantly decreased after surgery (p < 0.05). Especially in sleep duration, there was an increase in patients reporting intermediate sleep (4–7 h) and a proportion achieving a normal sleep duration of ≥7 h. And no significant differences of BPI were observed among different affected locations. The incidence of adverse events in the 0.5% doxorubicin group and 0.33% doxorubicin group was 8.78 and 6.34%, respectively.A total of 228 patients received 0.5% doxorubicin treatment and 63 received 0.33% doxorubicin. Both groups showed significantly improvement in visual analogue scale (VAS) and Brief Pain Inventory (BPI) scores. The 0.5% doxorubicin group demonstrated significant lower VAS scores at 6 and 12 months after surgery (all CT-guided doxorubicin injection therapy has the potential to alleviate pain and enhance the quality of life in patients with PHN. Notably, the use of a 0.5% doxorubicin concentration yields more pronounced pain relief compared to a 0.33% concentration. While longer durations of PHN and specific affected sites may influence the response to treatment, the overall improvements in quality of life remain consistent. Postherpetic neuralgia (PHN) is a chronic and recurrent neuropathic pain condition that occurs after the healing of herpes zoster (HZ) lesions .It affecDoxorubicin is a widely employed chemotherapeutic agent that inhibits DNA replication and induces cell death in cancer treatment . It has Therefore, this study aimed to evaluate the impact of different doses of doxorubicin in CT-guided injections for PHN treatment and the impact of 0.5% doxorubicin treatment on patients with varying disease courses and lesion locations.This retrospective study collected data from inpatients with PHN who received CT-guided doxorubicin injection treatment. The data was obtained from the clinical study database management system for PHN at West China Hospital, Sichuan University, spanning the period between April 2014 and February 2020. The study received approval from the Institutional Review Board, and informed consent was waived due to the retrospective nature of the study.The inclusion criteria were as follows: (1) Age > 18 years; (2) Persistence of pain after the resolution of herpes zoster rash for at least 1 month; (3) Presence of rashes distributed in any region of the body; (4) Baseline pain assessed using the visual analogue scale (VAS) with a score of 4 or higher; (5) Patients who underwent CT-guided injection of doxorubicin into the paravertebral or trigeminal semilunar ganglia. The exclusion criteria were as follows: (1) Patients with PHN resulting from multiple episodes of herpes zoster; (2) Patients who underwent other neuromodulation surgeries, such as radiofrequency modulation of the dorsal root ganglion or absolute alcohol block of the intercostal nerve; (3) Individuals experiencing severe pain due to conditions other than PHN, such as secondary neuralgia caused by tumor invasion of the corresponding nerve segment, primary intercostal neuralgia without a history of herpes zoster, or primary trigeminal neuralgia.Our department’s pain specialists are responsible for conducting thorough pain assessments, providing analgesic treatments, performing interventional procedures, and ensuring the ongoing health surveillance. In this context, patients with PHN underwent an initial pain evaluation to establish their baseline condition, and subsequently, they were assigned to receive doxorubicin injections following careful preoperative preparation. For spinal PHN, the CT guidance was used to locate three adjacent intervertebral foramina in the corresponding segment. A 21G, 10 cm puncture needle was then inserted, and upon reaching the target, a mixture of diprospan and lidocaine was injected. 1 mL of 0.33% or 0.5% doxorubicin was injected into each segment after drug diffusion confirmation. In trigeminal cases, foramen oval localization using a 21G, 15 cm needle under CT guidance was done, and doxorubicin was administered after observing the patient for 5 min without any adverse reactions. Throughout the follow-up and data recording processes, the nurse specialist assessed specific parameters at regular intervals, including pain levels using the VAS, pain characteristics using the DN4 questionnaire, analgesic usage, and the impact of pain on the patient’s quality of life as measured by BPI.Patient data related to PHN were retrieved from an existing study database by two physicians uninvolved in surgical procedures or follow-up evaluations. The collected information included gender, age, disease duration, lesion location, as well as preoperative and postoperative pain assessment, sleep quality, quality of life (QOL), occurrence of adverse reactions, and medication usage at 1 week, 3 months, 6 months, and 12 months after treatment. However, for the 0.33% doxorubicin group, due to incomplete information in the database, we were only able to obtain data for postoperative 6 months and 12 months regarding the BPI scores.Pain assessment included VAS for pain intensity and DN4 questionnaire  for paint-test if meeting a normal distribution or using rank sum test if skewed distributed. The categorical variables were expressed as number and percentage [n (%)] and analyzed using the chi-square test. Paired rank sum tests were used to analyze changes within the same group at different follow-up time points for count data and ranked data. Two-sided value of p of less than 0.05 was considered statistically significant.Statistical analysis was performed using SPSS 26.0 software . The continuous variables were presented as mean ± standard deviation (SD) and analyzed using Student’s t-test or paired sample p = 0.048), there was no significant difference in age, gender and the proportion of duration of disease between the 0.5% doxorubicin and 0.33% doxorubicin groups . The majority of patients in both treatment groups had a disease course of ≤3 months, and the most common disease site was the chest  . Among the chest .p < 0.001; 2.18 ± 1.44 vs. 3.10 ± 1.97, p < 0.001, respectively).The 0.5% group demonstrated significant lower VAS scores than the 0.33% group at 6 and 12 months after surgery (p < 0.05 compared to the preoperative group). The baseline DN4 score was 4.61 ± 0.98, which decreased to 0.88 ± 0.90, 1.71 ± 1.36, 1.30 ± 1.29, and 0.86 ± 1.01 at 1 week, 3 months, 6 months, and 12 months after surgery, respectively (p< 0.05 compared to the preoperative group). The scores were lowest at 1 week after surgery, gradually increased at 3 months, and then showed a gradual decrease over time. Regarding the pain attacks, approximately 71% of patients experienced persistent or more than 20 episodes pain attacks per day at baseline  (p < 0.05). At 12 months, patients with a duration of 4–6 months (2.19 ± 1.38) and 7–12 months (2.30 ± 1.50) also had significantly lower VAS scores compared to those with a duration of >12 months   . In the  < 0.05) . Patient < 0.05) .p < 0.05) , and this difference was statistically significant ( < 0.05) .p < 0.05). Specifically, the BPI score at 3 months was significantly higher than at 1 week post-surgery (p < 0.05). Various aspects of quality of life, including daily life, enjoyment of life, sleep, relationships with others, normal work, walking ability, and emotions, significantly declined after surgery (p < 0.05). Regarding sleep duration, there was a significant increase in the proportion of patients with intermediate sleep duration (4–7 h). This proportion remained consistent at 61.0–64.0% during the 3–12 months post-surgery. Additionally, the proportion of patients achieving a normal sleep duration (≥7 h) at each follow-up time point after surgery improved, with values of 39.4, 30.7, 22.4, and 30.7% .When stratifying by dermatome, the total BPI scores in the neck and upper limb groups were higher than in other groups at 6 and 12 months after surgery, with values of 16.36 ± 13.28 and 11.07 ± 10.63, respectively. However, no statistical difference was observed (p > 0.05).A stratified analysis based on disease course and affected location was performed to assess the impact of 0.5% doxorubicin treatment on quality of life . The totBefore surgery, the most commonly used drugs among PHN patients were pregabalin (86.4%), oxycodone aminophen (70.2%) and lidocaine cream (35.1%). After the treatment of 0.5% doxorubicin, there was a significant reduction in the proportion of combined medication compared to the pre-surgery period (p < 0.05). The percentage of patients using combined medication at each follow-up time point after surgery was 55.7, 33.8, 19.3, and 5.7%, respectively . There wAmong the 228 patients with 0.5% doxorubicin treatment, the total incidence of adverse reactions was 8.78%, including 12 cases of postoperative dizziness and nausea, 4 cases of palpitations, and 4 cases of local pain. Additionally, among the 63 patients with the 0.33% doxorubicin treatment, the total incidence of adverse reactions was 6.34%, including 2 cases of dizziness and 2 cases of pain at the puncture site.The results showed that both the 0.5% doxorubicin and 0.33% doxorubicin groups exhibited significant improvements in VAS and BPI scores following surgery. Moreover, the 0.5% doxorubicin group had significantly lower VAS scores compared to the 0.33% doxorubicin group at 6 and 12 months post-surgery. Notably, the 0.5% doxorubicin group demonstrated a greater reduction in VAS scores while maintaining similar safety profiles. Within the 0.5% doxorubicin group, the lowest scores were observed 1 week after treatment, followed by a slight increase at 3 months, and subsequent decreases over time. Patients with longer disease durations (≥ 12 months) exhibited higher scores. These findings provide evidence of the effectiveness of 0.5% doxorubicin in pain reduction, underscore the importance of early intervention in pain management, and emphasize the need for individualized treatment approaches based on the anatomical location of pain.This study demonstrated significant improvements in both pain levels and quality of life following CT-guided doxorubicin injection for PHN. The sensation of pain in PHN may be attributed to abnormal firing in nociceptors and low-threshold afferents. Previous research has indicated substantial cellular, axonal, and myelin loss, accompanied by fibrosis, in the sensory ganglia of individuals with severe PHN. By selectively targeting the affected area, doxorubicin has the potential to disrupt the associated signaling pathway and provide pain relief . These fIt is important to note that while 0.33 and 0.5% concentrations are commonly used in doxorubicin injections for PHN , limited2 (body surface area) implemented to minimize the risk of cardiac toxicity in clinical practice  in PHN, which affects up to 50% of cases . The higThe study has several limitations. Firstly, its retrospective design introduces inherent limitations, including potential selection bias and lack of control over confounding variables. Secondly, although the sample size was adequate for a single-center study, the generalizability of the results to a broader population may be limited. Additionally, the study duration and follow-up period were relatively short. Future studies with larger, multicenter cohorts and longer follow-up periods are warranted. Lastly, the assessment of pain and quality of life relied on subjective measures, which can be influenced by individual perception and reporting bias. Including objective outcome measures and employing blinding techniques would enhance the validity of the findings. Despite these limitations, the study provides valuable insights into the effectiveness of CT-guided doxorubicin injection therapy in treating PHN, highlighting the need for further investigation and improvements in study design.CT-guided paravertebral doxorubicin injection improves pain relief and quality of life in patients with PHN. The effectiveness of 0.5% doxorubicin is superior to 0.33% while ensuring a similar level of safety. Although patients with longer durations and chest affected sites may experience a lower pain relief response, the overall improvement in quality of life remains consistent across treatment segments.The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding authors.The studies involving humans were approved by the Ethics Committee of West China Hospital, Sichuan University, Chengdu, China. The studies were conducted in accordance with the local legislation and institutional requirements. Written informed consent for participation was not required from the participants or the participants' legal guardians/next of kin in accordance with the national legislation and institutional requirements.FL: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Resources, Software, Supervision, Validation, Visualization, Writing – original draft, Writing – review & editing. JWZ: Data curation, Formal analysis, Investigation, Methodology, Project administration, Software, Validation, Visualization, Writing – original draft. HL: Conceptualization, Data curation, Methodology, Project administration, Resources, Supervision, Validation, Visualization, Writing – review & editing. HX: Conceptualization, Methodology, Project administration, Resources, Supervision, Validation, Visualization, Writing – review & editing.This study was supported by grants from the Sichuan Science and Technology Program (No. 2022YFS0300) and West China Hospital of Sichuan University Clinical Research Incubation Project (No. 2021HXFH049).The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Hospitalizations are a vital opportunity for the initiation of life-saving opioid agonist therapy (OAT) for patients with opioid use disorder. A novel approach to OAT initiation is the use of IV buprenorphine for low dose induction, which allows patients to immediately start buprenorphine at any point in a hospitalization without stopping full agonist opioids or experiencing significant withdrawal.This is a retrospective case series of 33 patients with opioid use disorder concurrently treated with full agonist opioids for pain who voluntarily underwent low dose induction at a tertiary academic medical center. Low dose induction is the process of initiating very low doses of buprenorphine at fixed intervals with gradual dose increases in patients who recently received or are simultaneously treated with full opioid agonists. Our study reports one primary outcome: successful completion of the low dose induction  and three secondary outcomes: discharge from the hospital with buprenorphine-naloxone prescription, self-reported pain scores, and nursing-assessed clinical opiate withdrawal scale (COWS) scores over a 6-day period, using descriptive statistics. COWS and pain scores were obtained from day 0 (prior to starting the low dose induction) to day 5 to assess the effect on withdrawal symptoms and pain control.Thirty patients completed the low dose induction . Thirty patients  were discharged with a buprenorphine prescription. Pain and COWS scores remained stable over the course of the study period. Mean COWS scores for all patients were 2.6 (SD 2.8) on day 0 and 1.6 (SD 2.6) on day 5. Mean pain scores for all patients were 4.4 (SD 2.1) on day 0 and 3.5 on day 5 (SD 2.1).This study found that an IV buprenorphine low dose induction protocol was well-tolerated by a group of 33 hospitalized patients with opioid use disorder with co-occurring pain requiring full agonist opioid therapy. COWS and pain scores improved for the majority of patients. This is the first case series to report mean daily COWS and pain scores over an extended period throughout a low dose induction process. In 2021 there were an estimated 107,622 deaths in the United States from drug overdoses, representing a 15% increase from the year prior and a 30% increase from 2019 –11. OpioThere are many reasons for these missed opportunities including stigma, provider hesitancy or inexperience, and federal regulations limiting methadone prescribing for OUD in the outpatient setting –26. An aLow dose induction is the practice of administering very low doses of buprenorphine at fixed intervals with incremental dose increases such that the displacement of full agonist opioids at the µ-opioid receptor is so gradual that POW symptoms do not occur or are clinically attenuated , 34. It In the United States, buprenorphine is orally available in sublingual film and tablet forms, with the most common low dose being 2 mg. As shown in Table In this paper we present a retrospective case series examining 33 hospitalized patients with OUD and concurrent pain requiring full agonist opioids who underwent low dose induction utilizing IV buprenorphine. Data was abstracted over a 10-month period from May 1st, 2021, to March 1st, 2022, at an urban, tertiary academic medical center with a Level I Trauma Center. Additionally, we report average daily COWS and pain scores throughout the low dose induction process, a first for a case series of this size.We performed a retrospective chart review of patients who received IV buprenorphine from May 1st, 2021, to March 1st, 2022. Inclusion criteria were use of IV buprenorphine for the purposes of low dose induction and receiving full agonist opioids for pain control during the day prior to induction. Exclusion criteria were use of IV buprenorphine for any other reason and not requiring full agonist opioids for pain control the day prior to induction. We also excluded patients who were receiving methadone only for OUD and did not have co-occurring pain. When appropriate patients were identified, researchers performed a manual chart review to obtain all clinical opiate withdrawal scores (COWS) and pain scores over a 6-day period, starting at midnight the day prior to the initial IV buprenorphine administration and extending for the first 5 days of the low dose induction. COWS measures opioid withdrawal severity on an ascending scale from 0 to 48, while pain scores were self-reported on a scale of 0–10 . Both weReview of patient charts identified 2 distinct low dose induction strategies: a “standard” and a “slow” regimen  who required a change to the initially ordered protocol: 10 (37.0%) in the standard regimen and 1 (16.7%) in the slow regimen. We identified 5 primary reasons for dosage adjustment Table : worseniDuring the low dose induction, COWS and pain scores downtrended between day 0 and day 5 for most patients and were on-average low throughout the process  and by day 5 was 1.6 (SD 2.6), while the mean pain score on day 0 was 4.4 (SD 2.1) and by day 5 was 3.5 (SD 2.1), suggesting that the low dose induction process did not cause worsening withdrawal or complicate pain control, even for a cohort of patient with active pain control needs. By reporting daily COWS and pain scores throughout the induction period, this study hopes to demonstrate that low dose induction is generally well-tolerated, even for patients requiring full agonist opioids for pain, opening the door to buprenorphine treatment for a range of hospitalized patients who might not otherwise be considered candidates due to ongoing full agonist opioid requirements or due to recent use of methadone or non-pharmaceutical fentanyl.This paper has a number of limitations including imprecision in the reporting of data: day 1 begins with the first administration of IV buprenorphine but day 2 resets at a midnight-to-midnight interval. This means that day 0 encompasses a greater than 24-h period and day 1 a shorter and variable time period. Another limitation is lack of information about adjunctive medications such as ondansetron, dicyclomine, clonidine, and loperamide, which are frequently used to mitigate opioid withdrawal symptoms.Additionally, there was variability in the number and frequency of pain and COWS scores recorded Table , with leAs the opioid epidemic worsens, hospitalizations are increasingly understood as a crucial opportunity to engage patients with opioid use disorder and initiate OAT. By and large, hospital systems fall short of providing evidence-based care to patients with OUD, with prior studies suggesting that 11–15% of patients receive OAT during hospitalizations , 53. TheLow dose induction enables patients with OUD to start buprenorphine immediately upon hospital admission, without waiting for withdrawal symptoms to develop, and to receive full agonist opioids at any point during or after the induction process. Previously restricted to the realm of short case reports, low dose induction is increasingly coming into the clinical mainstream, and we hope it will soon be in the pharmacological toolkit of most hospital systems. The use of IV buprenorphine at the onset of low dose induction is easily protocolized, affordable, and pharmacologically precise . It aver


Verbal rating scales (VRS) are widely used in patient-reported outcome (PRO) measures. At our institution, patients complete an online instrument using VRSs with a five-point brief response scale to assess symptoms as part of routine follow-up after ambulatory cancer surgery. We received feedback from patients that the brief VRS descriptors such as “mild” or “somewhat” were vague. We added explicit descriptors to our VRSs, for instance, “Mild: I can generally ignore my pain” for pain severity or “Somewhat: I can do some things okay, but most of my daily activities are harder because of fatigue” for fatigue interference. We then compared responses before and after this change was made.The symptoms investigated were pain, fatigue and nausea. Our hypothesis was that the explicit descriptors would reduce overall variance. We therefore compared the coefficient of variation of scores and tested the association between symptoms scores and known predictors thereof. We also compared time to completion between questionnaires with and without the additional descriptors.p = 0.004). Total completion time was longer when the instrument included the additional descriptors, particularly the first and second time that the questionnaire was completed.A total of 17,500 patients undergoing 21,497 operations were assigned questionnaires in the period before the descriptors were added; allowing for a short transition period, 1,417 patients having 1436 operations were assigned questionnaires with the additional descriptors. Symptom scores were about 10% lower with the additional descriptors but the coefficient of variation was slightly higher. Moreover, the only statistically significant difference between groups for association with a known predictor favored the item without the additional language for nausea severity (Adding descriptors to a VRS of post-operative symptoms did not improve scale properties in patients undergoing ambulatory cancer surgery. We have removed the additional descriptors from our tool. We recommend further comparative psychometric research using data from PROs collected as part of routine clinical care.The online version contains supplementary material available at 10.1186/s12955-023-02184-0. Verbal rating scales (VRS) are widely used in patient-reported outcome (PRO) measures. In a typical application, the patient is asked about symptom severity and given the response options “none / mild / moderate / severe” with or without the addition of a fifth option of “very severe”.At Memorial Sloan Kettering Cancer Center (MSKCC) we use the five-item version of the VRS in our routine assessment of post-operative symptoms in patients undergoing ambulatory surgery . PatientWe received informal feedback from patients that the VRS descriptors are vague. Patients told us that they were unsure how to interpret descriptors such as “mild” or “moderate”. A common occurrence was that a patient would report a symptom as “severe” on the Recovery Tracker, but would then be surprised when subsequently called by a nurse, stating that the symptom was perfectly manageable.We had previously conducted research demonstrating the superiority of a VRS compared to a visual analog scale for post-exercise muscle soreness . One feaIn a discussion amongst the clinical team, without the express input of patients, we chose to characterize symptom intensity in terms of mental intrusiveness. Using pain as an example symptom: “None or very mild: I have no pain or hardly any pain at all”; “Mild: I can generally ignore my pain”; “Moderate: I can ignore my pain at times”; “Severe: It is difficult to ignore my pain”; “Very severe: It is difficult to think about anything else”. Comparable language was used for other symptoms, for instance, “Moderate: I can ignore my fatigue at times”. For symptom interference, the additional descriptors were based on the degree of difficulty that the symptom caused for daily activities. Using pain interference as an example: “Not at all or very little: I was able to do my daily activities with very little trouble or no trouble at all”; “A little bit: I can do most of my daily activities without any problem, but some are a little harder because of pain”; “Somewhat: I can do some things okay, but most of my daily activities are harder because of pain”; “Quite a bit: Pain makes it hard to live my normal life”; “Very much: It is very difficult to do any of my daily activities because of my pain”. The full text of questions before and after the change is given in the Rather than simply implementing the new VRS with explicit descriptors, we chose to study its characteristics in comparison to the VRS with the brief descriptors. We initially considered a randomized design but, given our large database of patients who had completed the VRS using simple descriptors, and the lack of any time trends in our data, we chose instead an interrupted time-series approach. We implemented the new descriptors and then compared the properties of the revised instrument to our historical experience. Our objective was to determine whether adding descriptors to a VRS measuring post-operative symptoms would improve its psychometric properties. These were defined in terms of the variance of symptom scores, and also the strength of the correlation between symptom scores and known predictors of post-operative outcomes.All patients in the study were undergoing ambulatory surgery for localized cancer at the Josie Robinson Surgery Center (JRSC) at MSKCC. The characteristics of patients treated at the JRSC have been described previously . In geneUnder a waiver from the Internal Review Board at MSK for retrospective research, we pulled data for all patients treated at JRSC from the date of the initiation of the Recovery Tracker in the respective services through February 21, 2022 to obtain just over 3 months of questionnaires that included the additional descriptors. We excluded patients who underwent surgery from October 30, 2021 to November 8, 2021 as they would have been transitioned between questionnaire types during the ten-day postoperative period when they receive the Recovery Tracker. We decided to analyze only pain, fatigue and nausea, on the grounds that other symptoms were rarely reported: in the case of shortness of breath, for instance, only 2% of responses indicated moderate or greater severity.We hypothesized that adding descriptors to the items would decrease variance. As an illustration, take two patients who have very similar subjective experiences of pain on two consecutive days. It might be that they would nonetheless give different answers, one responding “mild” and the other “moderate” due to the vagueness of these terms; they might be less likely to give different responses for “generally ignore my pain” vs. “I can ignore my pain at times”. If the use of additional descriptors reduces this source of variance, that would reduce total variance and increase the correlation between symptom scores and known predictors of that symptom.rds of the operations from the initial period as our training dataset to test the association between predictors of interest and responses using multivariable mixed effects linear regression, adjusting for postoperative day (POD) of the questionnaire along with its cubic splines. As patients may have multiple surgeries and questionnaires are sent out PODs 1–10, we included a nested random effect intercept varying among patients and among surgeries within each patient. We selected statistically significant predictors established in the training set and use those predictors to build multivariable mixed effects linear regression models adjusting for POD (and cubic splines) separately in the remaining 1/3rd of operations in the initial period and all responses using the additional descriptors, with a nested random effect intercept varying among patients and among surgeries within each patient. To test whether the effect of the selected predictors differed by cohort we tested for an interaction between age and questionnaires, with and without the additional descriptors, after adjusting for the main effects plus postoperative day (plus cubic splines), with the nested random effect using multivariable linear mixed effects models.To test the former, we calculated the mean and standard deviation of each symptom, comparing between responses given with and without the additional descriptors. For the second hypothesis, we investigated predictors that have been established in the literature to be associated with each symptom: age with pain  and fatiAs a secondary analysis we tested whether there was a difference in the time to questionnaire completion by questionnaire type using a linear mixed effects model with time to questionnaire completion as the outcome. We used a nested random effect intercept varying among patients and among surgeries within each patient and a fixed effect for questionnaire type as the predictor of interest adjusting for number of prior questionnaires completed after their most recent surgery along with its cubic splines. All analyses were conducted using R 4.1.2.A total of 21,497 operations for 17,500 patients were assigned questionnaires in the initial study period and 1,436 surgeries representing 1,417 patients were assigned questionnaires with additional descriptors. Patient characteristics by questionnaire type assigned are displayed in Table Symptom scores in each period are shown in Table p ≥ 0.1) except for nausea severity, where there was a statistically significant difference in the opposite direction to that hypothesized (p = 0.020). In an additional analysis for the nausea symptom, the size of the association between Apfel score and outcome was also significantly smaller when the additional descriptors were used (p = 0.006).For our analyses studying the association between predictors and symptom scores, the results of the preliminary analyses on the training set are shown in Supplemental Tables p < 0.001). It took patients much longer to complete the questionnaire with additional descriptors for the first and second questionnaire seen; the estimated time to completion was 16 vs 9.1 min and 9.2 vs 6.1 min. The time to completion was relatively similar thereafter.Mean time to questionnaire completion is displayed in Fig. We hypothesized that adding explicit descriptors to a VRS used in a PRO instrument would decrease the variance of PRO scores and improve correlation with known predictors, without unduly affecting time to questionnaire completion. We found, instead, that use of the additional descriptors increased time to completion importantly, particularly for the first questionnaires completed by the patient, without any beneficial effects on PRO properties. We have accordingly switched back to simple descriptors without the additional language for use in clinical practice. We did so even though the instrument with the additional descriptors would no doubt meet the typical criteria for validation of a PRO instrument.Our study is a rare example of health-related, psychometric research comparing two versions of the same item. It is not unusual for entire instruments to be compared. For instance, Hjermstad et al. reported a systematic review of 54 papers comparing VRS, visual analog scales (VAS) and numerical rating scales (NRS) of pain . AnotherThat said, there are few quantitative analyses comparing versions of the same health-related questionnaire with alternative wording choices. Most typically, a questionnaire is developed, from initial focus groups with patients to external validation, with quantitative comparison restricted to item selection. To illustrate this point, we chose, pretty much at random, the Anaphylaxis Quality of Life Scale for Adults . The invOf interest, in their review of pain instruments , HjermstOur experience demonstrates that comparative research on PROs can be conducted easily and inexpensively when piggy-backed on electronic PROs implemented as part of routine clinical care. We were able to analyze data on over 50,000 questionnaires with zero costs for research data collection. The cost of the research is minor, being restricted to investigator meetings, regulatory administration (for the IRB waiver) and statistical analysis.The size of our study is in some contrast with prospective research specifically conducted to investigate psychometric questions, which rarely includes more than 1000 respondents. This can have substantial implications for methodologic research. Take a study where patients received one of two different scales. To detect a 0.05 standard deviation (SD) difference between the scales would require ~ 12,500 subjects for 80% power. This is far from a trivial difference: a trial of a novel treatment with 80% power to detect a moderate effect size of 0.3 SD would have power of only 65% if using an inferior scale that resulted in a 0.25 SD difference between groups.A possible limitation of our study is the relatively high rate of unanswered items. This is expected as, first, not all patients have access to the patient portal and second, many patients stop answering the daily questionnaires before the final one is sent at 10 days because they have fully recovered and are not experiencing any operative symptoms at that point. The rate of missing data is slightly lower for the additional descriptors, likely due to increased use of the portal over time. However, there is no reasonable mechanism by which missing data could have an important effect on our main finding that use of additional descriptors did not improve the association between symptom scores and known predictors thereof.While we have removed the additional descriptors for the Recovery Tracker, we would caution against any over-interpretation of our findings. It would be unsound to make a general conclusion that additional descriptors for symptom states are unhelpful. First, the value of additional descriptors may depend on mode of administration. Specifically, about 70% of responses were completed using a mobile phone, where the small screen would favor a shorter response option. Second, additional descriptors may have greater or lesser utility depending on chronicity or type of symptom. For instance, the additional descriptors were particularly problematic for nausea. This may be because symptom tends to come and go during the course of a day, compared to pain, which is a more constant level of severity. Indeed, the poorer properties of the item with additional descriptors may be related to a focus on severity rather than duration: the original item was “how often do you have nausea?”. Third, there may be better descriptors for severity than those based on the mental intrusiveness of a symptom, and better descriptors for interference than those based on difficulty with everyday activities. One obvious explanation for our findings is that the additional descriptors led to additional variation, for instance, patients varied in how they interpreted “generally ignore” compared to “ignore at times”. Hence further research might examine alternative descriptors less open to variations in interpretation. Research might also examine whether additional descriptors might be of value in situations where patients experience only one symptom at a time, as it is plausible that perceptions of how much a symptom can be ignored depend on the presence of other symptoms.In conclusion, adding descriptors to a verbal rating scale of post-operative symptoms did not improve scale properties in patients undergoing ambulatory cancer surgery. We recommend further comparative psychometric research using data from PROs collected as part of routine clinical care.Additional file 1.


The limited number of randomized controlled trials (RCTs) comparing the efficacy of soft tissue manual therapy and self-therapy interventions prompted the authors to focus on the analgesic and myorelaxant use of massage, post-isometric muscle relaxation (PIR) and therapeutic exercise in TMD patients.To evaluate the effectiveness of soft tissue therapy and therapeutic exercises in female patients with pain, increased masseter muscle tension and limited mandibular mobility.The study was conducted on a group of 82 women (G1) with the Ib disorder diagnosed in DC/TMD . The control group (G2) consisted of 104 women without diagnosed TMDs . Diagnostic procedures were performed in both groups . The G1 group was randomly divided into 3 therapeutic groups in which the therapy was carried out for 10 days: therapeutic exercises (TE), manual therapy – massage and therapeutic exercises (MTM_TE), manual therapy – PIR and therapeutic exercises (MTPIR_TE). Each time after therapy, the intensity of pain and TMJ mobility were assessed. Sealed, opaque envelopes were used for randomization. After 5 and 10 days of therapy, bilateral sEMG signals of the masseter muscles were acquired.p = 0.0001). Each of the proposed forms of therapy showed a minimal clinically significant difference (MID) in the sEMG parameter at the endpoint, with the most considerable difference in the MTM_TE group. The forms of MT used were effective in reducing the patients’ pain intensity; however, a significant difference between therapies occurred after 4 treatments (p = 0.0001). Analyzing the MID between methods, it was observed that self-therapy had an analgesic effect only after 8 treatments, while PIR after 3 and massage after 1 treatment. After day 7, the mean pain score in the MTM_TE group was 0.889 and in the TMPIR_TE group was 3.44 on the NRS scale. In terms of MMO, a significant difference was obtained between monotherapy and each form of TM, i.e. massage (p = 0.0001) and PIR (p = 0.0001). Analyzing mandibular lateral movements, the authors got a significant difference in the proposed MT forms, of which massage treatments exceeded the effectiveness of PIR.Massage, PIR and self-therapy led to a decrease in sEMG at rest as well as in exercise. After day 6 of therapy, the groups obtained a significant difference (Soft tissue manual therapy and therapeutic exercise are simple and safe interventions that can potentially benefit patients with myogenic TMDs, with massage showing better analgesic effects than PIR.The online version contains supplementary material available at 10.1186/s13005-023-00385-y. Temporomandibular joint disorders (TMDs) may affect quality of life in an unprecedented manner. These might include, but are not limited to, being primary sources of chronic pain, impairment of chewing, swallowing threshold, speech, and breathing function, gradually becoming one of the major public health problems , 2. ThusAccording to epidemiological data, a large proportion of the world’s population is affected by TMDs, with an estimated 25% of adults presenting with physical and/or visible symptoms .In recent years, there has been a significant development in the knowledge of the etiology and treatment of the aforementioned problems. With the continuous search for better diagnostic and therapeutic approaches, attention has been directed at the possibility of using non-invasive therapeutic strategies in patients with TMDs symptoms . In partIn daily clinical practice, it can be observed that TMD treatment is usually carried out by a team using several types of interventions, including splint therapy , physiotNumerous studies have evaluated the efficacy of TE in various subacute and chronic musculoskeletal pathologies –19, and The main goals of PT in TMDs are to reduce pain, lower hypertonic muscle hyperactivity and improve function in hypotonic muscles, restore TMJ joint mobility, which eventually leads to mandibular proprioception and biomechanics enhancement. PT treatment is usually reversible and non-invasive . PT methAccording to the contemporary definition given by International Federation of Orthopaedic Manipulative Physical Therapists (IFOMPT), MT should be understood as: “a specialized area of PT dedicated to the management of neuromusculoskeletal diseases, based on clinical reasoning and the application of highly specialized treatment methods, including manual techniques and therapeutic exercises” . MT has According to a study by Rashid et al., up to 72% of respondents found PT to be an effective form of TMD treatment, with the most effective treatments being therapeutic TMJ exercises (79%), ultrasound (52%), MT (48%), acupuncture/dry needling (41%) and laser therapy (15%) .In the literature, there is a growing number of current scientific studies evaluating the effectiveness of PT. On the contrary, the importance of soft tissue MT and therapeutic exercises requires further randomized controlled trials (RCTs), which are the best evidence for interventions , 32. TheMost scientific findings emphasize the effectiveness of masticatory muscle massage in the treatment of soft tissue disorders, achieving both muscle relaxation, improved tissue blood supply and joint range of motion and reduced pain . PIR is Therefore, we hypothesized that MT factors and self-therapy alter the bioelectrical function of the masseter muscle, possibly contributing to improved TMJ mobility. A reduction in muscle tension results in a decrease in pain intensity.This study investigates the effectiveness of applied manual factors and therapeutic exercises in eliminating pain and increased muscle tension in female patients with TMDs.The study was conducted on female patients from the University Dental Clinic of the Pomeranian Medical University in Szczecin, Poland. Patients (Polish women living in the West Pomeranian Voivodeship) between 20 and 45 years of age (median 28.1) diagnosed with myofascial pain with limited mouth opening (Ib) based on DC/TMD criteria were included in the study.Inflammation in the oral cavity that emerged as myospasm or preventive muscle contraction,Earlier splint therapy—could affect the value of the amplitude in the EMG examination, among other variables throughout a signal acquisition procedure.Pharmacotherapy  – some hormones and their replacements are known to affect muscle tone and pain intensity;Systemic diseases —they can affect muscle tone and pain intensity and range of motion TMJMental illness- they can affect muscle tone and pain intensity, both treated and untreatedLack of stability in the masticatory organ motor system—this affects muscle tone and pain intensity and range of motion TMJMasticatory organ injury—can affect muscle tone and pain intensity and range of motion TMJ, usually due to myospasm/local myalgia/preventive co-contractionPregnancy – as trimester-dependent estrogen/progesterone and relaxine interplay may affect muscle tone and pain intensity,Patients undergoing orthodontic treatment—can affect muscle tone and pain intensity and range of motion TMJ,Other types of inflammation in the oral cavity  – which usually yield in protective co-contraction,Fibromyalgia—can affect muscle tone, pain intensity and/ as well as range of motion in TMJ and cervical spine,Other specific contraindications for use of physical treatments in the MT, e.g. cancer therapy, some older models of artificial pacemakers, etc.Exclusion criteria included:n = 82). The patients qualified for the study underwent instrumental diagnostics  and the level of pain intensity was assessed on the NRS numerical scale  consisted of healthy women Patients (Polish women living in the West Pomeranian Voivodeship), aged 20 to 45 (median 29), without claimed TMDs and pain disorders , in whom SEMG tests were performed, and TMJ mobility measurements were performed.The control group . All participants gave their written consent. The study complies with the CONSORT guidelines for reporting randomized controlled trials [The research project was approved by the Bioethics Committee of the Pomeranian Medical University in Szczecin (no. KB – 0012/102/13). Information on the clinical trial registration is available at d trials .sEMG recordings from the masseter muscles were performed with a two-channel NeuroTrac MyoPlus 2 device with NeuroTrac software . Clinical Mode EMG was used during the study. To obtain precise sEMG measurements, a band-stop filter was used, which guarantees that the frequencies of 50 Hz and 60 Hz (mains) will not interfere with the recording of muscle activity (measured in microvolts). Specialized filtering allows sEMG to be measured with a precision of 0.1 µV.www.seniam.org). The neutral electrode was located on the cervical section—C7 styloid process, which is usually devoid of vastly active muscle fibers.Examination of the electrical activity of the masseter muscle at rest (Rest Test): the test was performed on relaxed and relaxed patients. The dental arches remained slightly open during the examination. In order to eliminate the registration of signals related to the electrical activity of the eye circular muscle, these persons had their eyelids closed during the measurements. The patients were instructed not to swallow saliva during the examination and to place their tongue in a resting position.Study of the bioelectrical activity of the masseter muscle during maximal muscle contraction (MVC): sEMG signal was recorded in a sitting position, while clenching the teeth, using the greatest possible force, within 5 s. The computer program with which the device cooperated registers the minimum and maximum values and calculates the average values of electric potentials.In order to avoid magnetic interference, when collecting sEMG measurements, the device was not placed in the vicinity of cell phones (< 4 m) or other sources that might interfere with the results. Two unipolar electrodes were used for the test, which were attached at a distance of 10 mm from each other. The main principle used in all subjects was to position the electrodes over the center of muscle belly, parallel to the path of its fibers (the lower electrode was placed approx. 5 mm above the mandibular angle and the upper electrode 10 mm above it); precise placement of the electrodes was preceded by careful palpation of each muscle. The masseter muscles bioelectrical signals were acquired in an upright sitting position, with the head in a natural, postural position, hands resting on the knees and feet resting on the ground. Before the electrodes were applied, the skin was cleaned with rubbing alcohol disinfectant, following electrode manufacturers’ manual and guidelines of Seniam project . Two subgroups received manual therapy and therapeutic exercises/massage—MTM_TE; PIR—MTPIR_TE), while the third subgroup was prescribed monotherapy—TE.In women with G1, the pain was assessed each time after therapy using the NRS scale, and the mandibular range of motion was evaluated. After the 5th and 10th therapeutic day, a follow-up sEMG examination was performed at rest and on exertion.In the therapeutic management, behavioral therapy was implemented first in all subjects, which consists of explaining the causes of the dysfunctions and ways of self-control of occlusal and non-occlusal parafunctions, especially in the form of clenching and grinding of teeth or excessive gum chewing. Great importance is placed on the patient’s cooperation in the treatment process. Patients were informed about the essence of self-monitoring of parafunctions, the pathophysiology of the dysfunction and the impact of the patient’s own therapeutic cooperation on the effectiveness of treatment. The PIR treatments were performed in the group MTM_TE and the massage treatments were performed in the MTPIR_TE group. A standard exercise regimen was tailored to all participants. The description of the intervention is included in Supplement p < 0.05 were considered significant. The analysis was performed in the R language in the RStudio software using the NparLD, ggplot2, ggpubr libraries. Minimal important difference was defined as 0.5 × SD for each Variable [The data were presented as a median with a quartile range due to significant deviations from the normal distribution assessed using the graphical method with the analysis of the histogram and the Q-Q plot. Due to significant deviations from the normal distribution, the dependence of the studied variables on time and between groups was performed based on the nparLD test, which is a non-parametric equivalent of the analysis of variance for repeated measurements. The Kruskall-Wallis test with the post-Hoc multiple comparison test was used to compare the baseline values of the parameters studied with the control group. Comparisons between the control group and the total study group were made using the U-Mann Whitney test. The values of Variable , 37.The results from the pre-test in the test and control group are presented first. The results from the sEMG study represent the mean value between the right and left masseter muscle.There was no difference in the age structure between the groups. In the diagnostic procedure, between G1 and G2, statistical differences were found in the sEMG value of the masseter muscle , all ranges of TMJ mobility and pain intensity . PT interventions in each subgroup  were followed by statistically significant changes in the parameter studied, with TM treatments showing a better effect than monotherapy . Physiotherapeutic interventions were followed by statistically significant changes in each of the subgroups  for the parameter studied, with TM treatments showing a better effect than monotherapy  there were statistically significant changes in the examined parameter, with TM treatments showing a better effect compared to monotherapy. Only the treatment with the use of massage led to complete pain relief Fig. .Figure The significant interaction effect of time and method indicates the highest effectiveness of MTM_TE among the methods tested (5a-c).Figure The significant interaction effect of time and method indicates the highest effectiveness of manual therapy among the methods studied (6a-c).Figure The significant interaction effect of time and method indicated that manual therapy was the most effective among the methods studied. Of these, MTM_TE proved to be the most effective method for pain alleviation Fig. .As shown in Table This study determined the analgesic and myorelaxant efficacy of MT and self-therapy treatments in female patients with TMDs. The bioelectrical function of the masseter muscles and the evaluation of mandibular movements in patients with and without TMDs were also scrutinized.p = 0.00). As can be seen from the diagnostic part of the study, subjects with TMDs have higher mean sEMG values of the masseter muscle at rest and during exercise. The increased bioelectrical activity of the masseter muscle is considered to influence the restriction of mandibular MMO ranges and lateral mandibular movements in the study group. As can be seen from the analysis, the mean pain intensity before PT was 6 (moderate pain) on the NRS scale. As shown by the results of studies conducted by other authors, increased muscle tension affects the range of mobility of the TMJ and contributes to pain [When analyzing the bioelectrical function of the masseter muscle at rest and exercise, the study’s authors observed a significant difference between the control group and those with TMDs , physiotherapist, psychologist and psychiatrist is key. When prescribing treatment, the first therapy recommended for a patient with pain and impaired joint function is MT combined with self-therapy and supplemented with behavioral therapy. Calixtre et al., in a systematic review of RCTs about studies on the effectiveness of MT in patients with TMDs, indicated that soft tissue therapy treatments applied to the masticatory muscles are even more effective than controls but as effective as botulinum toxin injections . They coAs can be seen from the study, each of the prescribed forms of physiotherapy altered the bioelectrical function of the masseter muscles, the range of mandibular mobility and the intensity of pain. Analyzing the individual parameters studied in relation to the proposed forms of therapy, it can be concluded that there were significant differences between the study groups.p > 0.05). Only at the 2nd time point (after 5 treatments) was a significant difference obtained between the groups (p = 0.0001). The result obtained may indicate the need for at least 5 TM treatments to improve the bioelectrical function of the muscle. Analyzing the above parameter at the time endpoint (i.e. after 10 treatments), it can be concluded that, of the proposed physiotherapeutic treatments, massage combined with TE (MTM_TE) proved to be the most effective form of therapy in patients with TMDs and outperformed in its effectiveness TEPIR_TE (p = 0.0001) and TE (p = 0.0001). The result obtained may indicate that muscle massage treatments have a more substantial effect on masticatory muscle activity. Each proposed therapy showed a minimal clinically significant difference in the sEMG parameter at this endpoint. The largest MID is seen in the TMM_TE group in both resting and exercise muscle activity. The smallest MID occurred in the TE group, and in exercise muscle function, this only occurred at the second time point (after 5 treatments). Single scientific reports similarly compare the effectiveness of TE, TM, and PIR in combination with self-therapy. A study by Urbanski et al. conducted on patients with TMDs found no significant difference, in terms of myorelaxant effect, between PIR and muscle-fascial therapy. In both groups, a decrease in masseter and temporalis muscle SEMG function was observed, as well as a reduction in pain intensity. The differences between the study results may be due to the use of a different methodology for conducting the soft tissue therapy procedure in the above study [Both massage, PIR and self-therapy led to a decrease in bioelectrical signals of the masseter muscle at rest as well as in exercise. When analyzing this parameter, the authors observed that no significant difference was obtained at the first time point between the TMM_TE, PIT_TE, and TE groups . This analgesic effect may occur due to MT pain modulation via activating low-threshold Aβ fibers pathway. This inhibits nociceptive stimuli from Aδ and C supply fibers , 43. MT p = 0.0001). Analyzing the minimal clinically significant difference between the methods, it was observed that auto-therapy had an analgesic effect only after 8 treatments (a decrease of 0.5 points), while in the MTPIT_TE groups after 3 (a reduction of 0.52 points) and MTM_TE after 1 treatment (a mean decrease of 2.63 points). It is noteworthy that, from a clinical point of view, after the 7th day of massage, the mean pain score on the NRS scale was 0.889, and that of the patients subjected to PIR was 3.44. Thus, it can be concluded that, of the proposed forms of physiotherapy, massage combined with TE is the most effective therapy for treating masseter muscle pain. The therapeutic importance of massage has been extensively described in a peer-reviewed publications recently. It is related to many factors, such as local blood and lymph flow, muscle activity and the nervous system [When assessing the analgesic effect of MT, the authors observed that, again, the most effective form of pain management was massage combined with autotherapy, which was superior to the other two treatment groups  between the PIR method and tension/counter-tension in the treatment of TMJ pain and mobility [According to a study by Rodrigez Blanco et al., the PIR technique of the masseter muscle proved to be a more effective method than the tension/counter-tension technique in patients with pain and limited mandibular visitation . In contmobility . Rajadurmobility .As shown in a study by Gomes et al. comparing the therapeutic effect of massage and splinting in an RCT in patients with TMDs, massage therapy on the masticatory muscles and the use of an occlusal splint leads to an increase in mandibular ROM similar to that in an asymptomatic comparison group in relation to maximum active mouth opening and right and left movement in TMD patients . On the p = 0.00).Another parameter assessed in this study was TMJ range of motion, which was significantly different in TMDs patients compared to healthy controls (p > 0.5). At other time points (from the 6th treatment onwards), a significant difference was obtained between monotherapy and each form of MT, with both massage (p = 0.0001) and PIR (p = 0.0001) significantly improving the MMO range. When analyzing the minimum clinically significant difference between methods, it was observed that TE was the least effective (1 point increase on day 7 of therapy). Between the TM methods, the clinical effect was comparable both after day 1 of treatment  and at the endpoint  and analgesic effects (p = 0.0001) and contributed to a significant increase in TMJ range of motion (p = 0.0001) compared to monotherapy.A study by Toucker et al. on the evaluation of MT and therapeutic exercises showed that, when combined, both forms of therapy yield clinically significant effects on both pain and pain-free maximal mouth opening in TMD patients . Also, iHerrera-Valencia et al., in their meta-analysis consisting of six papers on the effectiveness of MT in the treatment of TMDs, found that significant improvements in pain and MMO were observed after manual treatment compared to baseline values. According to their analysis, MT appears to be an effective treatment for TMJ disorders in the mid-term, although the effect seems to diminish over time. However, when combined with therapeutic exercise, these effects may persist for a long time . Also, Dp = 0.0005) and a reduction in pain, with a decrease of an average of three points on the NRS scale (p = 0.00002) [According to Byra et al., the PT procedure used, including MT and masticatory muscle exercises, improves TMJ range of motion and reduces pain in patients with TMJ hypomobility. Significant improvements in TMJ mobility were achieved, with an average increase of 6.6 mm (0.00002) . The the0.00002) .p = 0.00), which is a major strength of this study. Similarly, is the identification of a minimal clinically relevant difference, whereby it was observed that massage treatments surpassed PIR in their effectiveness, hence producing a better and faster therapeutic effect, especially with regard to pain intensity. The results obtained are auspicious, prompting the authors to continue this type of study in the future.The research carried out quite clearly demonstrated the superiority of the synergism of MT methods and therapeutic exercises over monotherapy (self-therapy), at very high significance (According to the authors, a limitation of the study carried out was the short duration of therapy the women underwent and the small size of the treatment subgroups. In addition, there was no evaluation of how long the therapeutic effect obtained during the applied treatments persisted after the therapy cycle. Therefore, the authors see a need to continue the study conducted, focusing on the above limitations.People with TMD should receive at least six manual therapy sessions to improve the bioelectrical function of the masseter muscle, with massage combined with autotherapy appearing to be a more effective therapy than PIR and autotherapy, which should be taken into account when selecting the form of therapy.Massage combined with self-therapy shows a significant analgesic effect in people with the painful form of TMD, leading to a significant or complete resolution of pain after the 7th day of therapy.Massage and post-isometric relaxation of the masseter muscle have comparable efficacy in improving mandibular mobility in patients with TMD.Manual therapy should be part of the therapeutic regimen for patients with TMD.Additional file 1: Supplement 1.


Pain remains one of the most difficult-to-treat domains in patients with rheumatoid arthritis (RA). In clinical trials, the Janus kinase inhibitors (JAKis) have demonstrated good efficacy in pain relief. Aim of our study was to evaluate the real-life effectiveness of JAKis in improving pain in patients with RA in different states of baseline disease activity. A monocentric prospective cohort of 181 RA patients starting treatment with JAKis was studied. Pain was evaluated on a 0–100 mm visual analogue scale (VAS). Clinically meaningful improvements over 24 weeks were defined as follows: proportion of patients achieving ≥ 30%, ≥ 50%, and ≥ 70% pain relief, and remaining pain ≤ 20 or ≤ 10 mm. Results were analysed after stratification for baseline inflammatory activity; patients with swollen joints and C-reactive protein ≤ 1 at treatment start were considered pauci-inflammatory. Proportion of patients who achieved ≥ 30%, ≥ 50% and ≥ 70% pain improvement at 24 weeks was 61.4%, 49.3% and 32.9%. Furthermore, 40.6% and 28.5% of the patients achieved thresholds of remaining pain equivalent to mild pain or no/limited pain. Pain improvements were more evident in patients naive to previous biologics, although nearly 30% of multiple failures achieved VAS ≤ 20 mm. No significant differences were observed in relation to monotherapy. Pauci-inflammatory patients at treatment start achieved good outcomes, with 40.4% experiencing ≥ 70% pain improvement, and 35.7% VAS ≤ 10 mm. JAKis show efficacy in pain relief in real life. The improvement of painful symptoms also in those patients with limited objective inflammation may open new perspectives on the management of difficult-to-treat RA. Outcomes of rheumatoid arthritis (RA) have dramatically improved over the past twenty years due to the recognition of the benefits of early diagnosis and treatment, as well as the increasing availability of a number of targeted disease-modifying antirheumatic drugs (DMARDs) . Still, Joint tenderness and widespread pain uncoupled from perceivable inflammation are thought to arise from central sensitization and maladaptive pain processing mechanisms  and are The Janus kinase-signal transducer and activator of transcription (JAK/STAT) pathway directly and indirectly modulates a multitude of pro- and anti-inflammatory cytokines , and ranFrom the biologic (b)/targeted synthetic (ts) DMARD dedicated clinic of the Division of Rheumatology of the San Matteo University Hospital of Pavia, we selected all RA patients who began the first JAKi from time of licencing of tofacitinib in Italy (October 2018) to June 2022 and had 6 months follow-up available. Intra-class switches (i.e. subsequent JAKis after a first JAK) and different clinical indications (e.g. psoriatic arthritis) were excluded.The study was conducted according to the declaration of Helsinki; all patients signed written informed consent before inclusion, and the local Ethics Committees approved the study protocol.At treatment start, demographic and clinical data were collected and included, among the others, disease duration, history of previous bDMARD exposure, and concomitant use of conventional synthetic (cs) DMARDs and glucocorticoids. Disease activity and impact were assessed at baseline and every 8 weeks thereafter through the following instruments: the tender and swollen joint count on 28 joints , the patient global assessment (PGA) and physician’s global assessment of disease activity on 0–100 mm visual analogue scales (VAS), VAS for general health (GH) and pain (0–100 mm), the erythrocyte sedimentation rate and C-reactive protein  levels. Rheumatoid factor (RF) and anti-citrullinated protein antibodies (ACPA) were evaluated on electronic records before treatment start. Patients were classified as autoantibody-positive if RF and/or ACPA were above the reference cut-off values; autoantibody-negative in case of RF and ACPA both negative. Date and reason for drug withdrawal during the study period were recorded.Achievement of disease remission according to the 28-joints disease activity score calculated with CRP levels (DAS28-CRP < 2.6), the clinical disease activity index (CDAI < 2.8) and Boolean criteria ; ≥ 30%, ≥ 50%, or ≥ 70% improvement of pain from baseline;Achievement of clinically meaningful thresholds of remaining pain: VAS pain ≤ 20 mm (mild pain) and ≤ 10 mm (no or limited pain) .After 8, 16 and 24 weeks of therapy, outcomes of interest included:SJC28 and CRP ≤ 1 = no or limited inflammationSJC28 > 1, CRP > 1, or both = overt inflammationOutcomes were analysed in the overall population and after stratification for baseline inflammatory activity according to SJC28 and CRP at treatment start:t test or chi statistics, as appropriate. All analyses were conducted using MedCalc® Version 12.7.0.0, and the significance level was set at 0.05.Quantitative data were expressed as means and standard deviations (SD) and categorical data as frequencies. There was no imputation of missing data. Remission status over time was analysed using the Kaplan–Meier method, and the time-course of pain scores using repeated measures analysis of variance. Comparisons between groups were made by means of independent samples n = 17, baricitinib n = 99 (8 receiving 2 mg/day), upadacitinib n = 47, filgotinib n = 18. The main demographic and clinical characteristic at treatment start are detailed in Table n = 60, 33.1%) lacked significant synovial and systemic inflammation (SJC28 and CRP ≤ 1) despite being highly symptomatic (mean [SD] VAS pain 51.1 [25.6]). The characteristics of this apparent non-inflammatory group in comparison with the rest of the cohort are detailed in Table The study population included 181 RA patients treated with a JAKi: tofacitinib n = 19, 10.5%), adverse events  or loss to follow-up . Adverse events included non-serious infections (n = 9), herpes zoster (n = 1), neutropenia (n = 2), neurosensory hear loss (n = 1) and renal dysfunction (n = 1). Now major cardiovascular events, venous thromboembolism or cancer were observed. As shown in Fig. During the 6 months of observation, 34 patients 18.8%) discontinued the JAKi after a mean (SD) of 16.4 (6.8) weeks due to clinical inefficacy  of  – 23.2 ( – 27.2 to – 19.2) mm, with no further major changes thereafter .Relevantly, pain improvement occurred to a similar extent in the subgroup of patients with no or limited inflammation (SJC28 and CRP ≤ 1) compared with the rest of the cohort Fig. A. The prIn this study, we provide evidence of the real-life effectiveness of JAKis in patients with RA in whom joint inflammation and painful symptoms were not controlled by the first or subsequent lines of therapy. We show that, beyond numerically significant reductions in pain scores, most patients experienced clinically meaningful improvements, with negligible residual pain in as many as 40% of the cases. Importantly, good pain outcomes were also achieved in patients escalated to treatment because of persistent pain in spite of limited discernible inflammation.The clinical effectiveness of JAKis on different components of disease activity and impact in moderate-to-severe RA is well established in RCTs . Most paStrengths of our study include the description of a prospective cohort reflecting the complexities of RA in clinical practice, with a significant number of patients deemed eligible to treatment escalation in spite of limited objective inflammation. Furthermore, rather than analysing changes in pain levels in mere numerical terms, we focused on outcomes that are clinically relevant to the patient. We acknowledge that our definition of pauci-inflammatory disease is arbitrary, and that the absence of clinically swollen joints does not exclude residual levels of subclinical inflammation. However, when the thresholds of stringent remission are satisfied, as in the case of SJC and CRP ≤ 1, the probability of ultrasound-detectable synovitis is low . Our ana


Moreover, patients with sternal instability (14%) and female patients with macromastia (25%) reported higher pain than those stable or without macromastia (both p < 0.05). No other risk factors were associated with pain. Thus, the IDSS seems to reduce the levels of pain and perceived effort during the supine-to-sitting postural change. Future studies with quantitative assessments are required to suggest the adoption of this technique, mostly in patients with high levels of pain or with sternal instability.Patients with sternotomy are advised to follow sternal precautions to avoid the risk of sternal complications. However, there are no standard recommendations, in particular to perform the supine-to-sitting postural change, where sternal asymmetrical force may be applied. The aim of this study was to compare the rotational movement and the use of a tied rope  to perform the supine-to-sitting postural change. A total of 92 patients  admitted to a rehabilitative post-surgery ward with sternotomy were assessed for sternal instability. Levels of pain and perceived effort during the two modalities of postural change and at rest were assessed. Patients reported higher values of pain and perceived effort (both  Median sternotomy is the gold standard in cardiac surgery incisions for the treatment of all congenital and acquired heart diseases . It is pCough and asymmetrical movements with upper limbs and trunk are the main risk factors for sternal displacement ,12,13,14Although the health facilities affect how indications are provided, 90% of the physiotherapists offered pre- and post-operative information, such as early mobilisation, post-sternotomy restrictions, techniques for bed/chair mobility, breathing exercises, coughing techniques, and information about exercising the lower extremities ,24. WhilThus, the aim of the present study was to evaluate which of the two postural change modalities, through a rotational movement or performed using the IDSS, was less painful and evoked less perceived effort, in order to identify which modality should be recommended to patients with sternotomy.This observational study was conducted between April and October 2022, at the Istituti Clinici Scientifici Maugeri IRCCS, Institute of Veruno, Italy. Patients were recruited among those admitted to the Cardiac Rehabilitation ward, those of which underwent surgery with median sternotomy under general anesthesia. All subjects met the following inclusion criteria: (1) presence of pain due to the sternotomy, defined as a score of at least 1 point on the numeric rating scale (NRS), during the postural change supine-to-sitting; (2) normal cognitive functioning ; (3) abThe study protocol was approved by the Ethics Committee of the Istituti Clinici Scientifici Maugeri, Italy  and all participants signed the informed consent.All subjects were evaluated the day of admission by a physiotherapist with at least ten years of experience in cardiac rehabilitation. Age, sex, height, weight, smoking history, comorbidities, presence of macromastia in women (EU bra size > 80), and measurement of chest circumference in an upright position, at the mamillar line with the use of a tape measure, were recorded. The following evaluations were used:SIS is a 4-point scale that aims to assess the stability of the sternum and assign a corresponding grade to the findings of examination as follows: 0, clinically stable sternum (no detectable motion)—normal; 1, minimally separated sternum ; 2, partially separated sternum—regional ; and 3, completely separated sternum—entire length  .The patient’s pain assessment was conducted via a self-reported NRS of 11 points, where 0 means no pain and 10 means worst pain . The NRSMoreover, the perceived level of effort during postural changes was rated using the NRS (0–10).After recording the subjects’ anthropometric data and evaluating sternal stability with the SIS scale, subjects were asked to perform the postural change from the supine to the sitting position. The postural change was carried out with two distinct techniques: (a) rotational postural change  and (b) Rotational postural change : (a) movPostural change using IDSS: (a) move the legs towards the edge of the bed, putting them diagonally; (b) tighten the IDSS with one hand, turning the palm upwards; (c) with the other hand, always with the palm facing upwards, grab the hand that already holds the IDSS; (d) pull the IDSS by bending the elbows and, at the same time, activate the abdominal muscles, bringing the trunk to 90° with respect to the bed plane; and (e) place your legs completely outside the bed top and settle in a sitting position.For both techniques, before performing the postural change, patients were in the semi-Fowler’s position, lying on the bed with a trunk inclination of 30° , while aDuring this procedure, a dynamometer was placed between the IDSS and the footboard of the bed in order to measure the peak force, expressed in kilograms–weight, exerted by the patient on the IDSS.At discharge from the cardiac rehabilitation ward, patients were instructed to use the learnt sternal precautions, such as performing the supine-to-sitting postural change with their most pain-free modality. Patients were interviewed through a follow-up call after 6 months from the discharge in order to report if they had serious complications, as would infection or sternal instability, that required other medical interventions.Mean ± standard deviation (SD) values were used for descriptive statistics and figures.A test for normality (Shapiro–Wilk) was performed in all recorded variables. Comparisons of mean pain levels during the three postural conditions  were made by one-way repeated-measure ANOVA tests. When ANOVA gave a significant result, the post-hoc Tukey test was conducted to assess differences between postural conditions. To detect differences in perceived level of effort between the two postural conditions  a paired Student’s t-tests was performed.The clinical meaning of differences between the two modalities of postural change was assessed through the calculation of the Cohen’s d effect size, with the commonly used interpretation that refers to effect sizes as small (d = 0.2), medium (d = 0.5), and large (d = 0.8) based on benchmarks suggested by Cohen .Then, to evaluate the effect of each risk factor , chronic obstructive pulmonary disease (COPD), obesity, and diabetes) on pain, a subgroup analysis was performed with patients divided for the presence/absence of the main factor risk. Sternal instability was defined as a score ≥ 1 on SIS, while the presence of macromastia as an EU bra size > 80. For each risk factor, a 2-way repeated-measures ANOVA was conducted with the groups (with or without each factor risk) as independent factors and within the three postural conditions . When ANOVA gave a significant result, the post-hoc Tukey test was conducted to assess differences between postural conditions.Spearman’s rank correlation was used to evaluate correlation among variables. Correlation coefficients (ρ) were interpreted as follows: strong correlation if the coefficient value lies between 0.50 and 1; moderate if the value lies between 0.30 and 0.49; and fair if the value lies below 0.29 .Sample size was calculated from El-Ansary et al. ; in thisStatistical analysis was performed using Statistica software .Of 181 patients admitted to our cardiac rehabilitation ward with median sternotomy, 92 patients (51%) met the inclusion criteria. The participants’ demographic and clinical data are reported in Patients were admitted and assessed between the fifth and the fifteenth day after surgery, with a mean time of 8.14 ± 2.62 days. The mean traction force exerted on IDSS during the postural change was 10.13 ± 4.20 kg.On the SIS, 79 patients (86%) reported a score of 0 , 7 (8%) a score of 1 , 5 (5%) a score of 2 , and only 1 (1%) the worst score of 3 (completely separated sternum).p < 0.0005). Post-hoc analysis showed that pain was significantly higher during the rotational postural change with respect to the other two conditions (p < 0.0005). No difference in pain was found between rest and IDSS. The difference of pain during rotational postural change and the other two conditions showed a large effect size . When analyzing the distribution of pain during the three different postural conditions, it emerged that patients experienced severe pain only in the rotational condition  and large, with an effect size of 1.84.Patients reported a mean perceived level of effort on NRS of 6.2 ± 2.5 points during the rotational movement and of 1.6 ± 1.7 points when using the IDSS. The difference between the two modalities of postural change was significant (p < 0.05), but there was no interaction between pain and conditions. Moreover, female patients with macromastia had higher pain value than those without macromastia  = 7.21, p < 0.05), even if there was no interaction between pain and conditions. No differences were found in the other subgroup analyses.Subgroup analysis revealed that subjects with sternal instability showed more pain than stable patients  = 4.79, p < 0.0005), while a moderate correlation emerged during the IDSS postural change . No other correlations were found between the remaining clinical variables and the assessment data.Pain at rest did not correlate with other clinical parameters, such as the time from surgical intervention (ρ = 0.001). A strong correlation was found between pain and perceived level of effort during the rotational postural change  reported sternal complications that required rehospitalization. Only a patient (1.1% of the whole sample), a woman without sternal instability during the rehabilitation recovery, had a subsequent sternal displacement.The aim of this study was to assess which modality of supine-to-sitting postural change, through a rotational movement or performed using the IDSS, induced lower levels of pain and perceived effort in post-operative patients with sternotomy. The results show that the postural change performed using the IDSS was less painful compared to the rotational modality. The level of pain reported by patients during the resting position and in performing the postural change using the IDSS was mild and almost similar between the two conditions. On the contrary, patients reported moderate levels of pain in performing the rotational postural change.The risk of sternal complications following median sternotomy is frequently reported in literature, suggesting that it would be customary to instruct patients to adopt sternal precautions in order to reduce the incidence of complications ,38. NeveAlthough these hindrances appear to be important, they seem not to be sufficient in order to reduce the risk of complications. Recent studies showed that in the same way, transfers and elevating both arms simultaneously overhead creates the greatest sternal separation ,39. In pTherefore, addressing limitations of the supine-to-sitting transfer seems to be important following median sternotomy. Although modifications to supine-to-sitting postural change using the technique encouraged as part of sternal precautions were shown to decrease stress compared to a typically discouraged method ,38, thesIn fact, finding alternative solutions appears to be essential for guaranteeing the safety of patients. Our work confirmed that more than 50% of patients who undergo sternotomy surgery report persistent pain in the sternum. These findings are superimposable to the study of Moore et al. , who fouMoreover, the use of IDSS seems especially important in the elderly who are accustomed to carrying out the supine-to-sitting transfer using the rotational pattern compared to younger adults who preferred to perform the postural change through the long sitting position . This beAmong risk factors associated with mechanical forces acting upon the sternotomy site, some were identified also in our sample: chronic obstructive lung disease ,43, macrIndeed, patient-reported pain was cited as being the main restriction used to guide exercise prescription and progression in the return to daily living movements . In the The good correlation found between pain and perceived level of effort, in both the modalities of postural change, may suggest that weaker patients experienced a higher level of effort in the strain, and consequently, more pain. However, this hypothesis needs to be verified.Finally, only the 1.1% of the total sample reported a complication, i.e., sternal instability, 6 months after hospital discharge. This result is in line with the noted cases of complications in literature (1–8% ). Thus, Results of our study are based only on patient-reported outcome measures (pain and perceived effort). One of the limitations was the lack of other types of measure, such as ultrasound. This useful technique might be use in future research to provide valuable real-time feedback regarding sternal healing in patients following cardiac surgery via median sternotomy and may allow for quantitatively assessing motion at the sternal edges. Another limitation was the simple follow-up call at 6 months after hospital discharge; since it is known that sternal healing continues beyond the first three post-operative months , we mighFuture research should implement the actual results measuring the motion at the sternal edges during the supine-to-sitting postural change, following patients over a post-operative period of at least 3 months, and assessing the supine-to-sitting abdominal muscles activation and the use of upper limbs to verify the relationship existing between pain, perceived effort, and level of effort in the strain. Moreover, future studies might stratify the population with sternotomy by clinical characteristics in order to give appropriate instructions for each subgroup.Sternal displacement is associated with unilateral and rotational movements and the supine-to-sitting postural change is one of the most challenging because of the force applied to the sternum. Thus, since the use of the IDSS seems to reduce the levels of pain and perceived effort during the supine-to-sitting postural change, future studies with quantitative assessments are required to verify its effectiveness and to suggest the adoption of this technique, mostly in patients with high levels of pain and in those with sternal instability.