Impaired rate-dependent depression of the Hoffman reflex (HRDD) is a potential biomarker of impaired spinal inhibition in patients with painful diabetic neuropathy. However, the optimum stimulus-response parameters that identify patients with spinal disinhibition are currently unknown. We systematically compared HRDD, performed using trains of 10 stimuli at five stimulation frequencies , in 42 subjects with painful and 62 subjects with painless diabetic neuropathy with comparable neuropathy severity, and 34 healthy controls. HRDD was calculated using individual and mean responses compared to the initial response. At stimulation frequencies of 1, 2 and 3 Hz, HRDD was significantly impaired in patients with painful diabetic neuropathy compared to patients with painless diabetic neuropathy for all parameters and for most parameters when compared to healthy controls. HRDD was significantly enhanced in patients with painless diabetic neuropathy compared to controls for responses towards the end of the 1 Hz stimulation train. Receiver operating characteristic curve analysis in patients with and without pain showed that the area under the curve was greatest for response averages of stimuli 2–4 and 2–5 at 1 Hz, AUC = 0.84 (95%CI 0.76–0.92). Trains of 5 stimuli delivered at 1 Hz can segregate patients with painful diabetic neuropathy and spinal disinhibition, whereas longer stimulus trains are required to segregate patients with painless diabetic neuropathy and enhanced spinal inhibition. A receptor function, from inhibitory to excitatory, has been demonstrated [A receptors, less hyperpolarising and potentially depolarising [There is increasing recognition that processes within the spinal cord are key to modulating neuropathic pain, through amplification or suppression of peripheral nociceptive inputs. The neurotransmitters γ-aminobutyric acid (GABA) and glycine play a critical inhibitory role in regulating spinal nociceptive processing ,2,3. Dianstrated . Currentlarising . This prlarising . A potential biomarker of spinal disinhibition is rate-dependent depression of the H-reflex ,8. The HA inhibition, suggesting that they share a common pathogenic mechanism; spinal disinhibition [Both a loss of HRDD and altered behavioural indices of neuropathic pain are seen in rodent models of diabetes . Moreovehibition ,7. Our rhibition ,15. We sCurrently, it is not known which HRDD parameters best distinguish between these sub-groups of patients. In preclinical and clinical studies, the stimulation trains used for eliciting HRDD have been of variable length and frequency, and HRDD has been calculated using a variety of individual or average response sequences. In our proof-of-concept clinical study in patients with diabetes, trains of three stimuli were delivered . HRDD waUsing signal detection theory methods, the purpose of the current investigation was to systematically assess which stimulation and response parameters best distinguish between patients with and without pain. This is critical to allow wider application of this technique as a balance needs to be struck between obtaining the most useful and relevant information with the practicalities of performing and tolerability of the investigation. To explore the utility of HRDD as a biomarker in painful diabetic neuropathy, we compared response trains at increasing stimulus frequencies, with the aim of defining the optimal parameters to segregate patients with spinal inhibitory dysfunction as a dominant pain mechanism. Patients were recruited from secondary care diabetes clinics at one NHS trust over a period of 24 months. Convenience sampling was used, and all eligible patients were given the opportunity to take part in the research study. Control subjects were recruited via hospital and University advertisements. Written informed consent was obtained for each participant. Study conduct adhered to the tenets of the Declaration of Helsinki and Research Ethics Committee approval was granted on 28 February 2017 . n = 53), patients without painful diabetic neuropathy (n = 75) and healthy control subjects (n = 36) were studied. The H-reflex was absent in 24 patients with diabetes (10 with type 1 and 14 with type 2 diabetes) and 2 control subjects, and these subjects were excluded from further assessment. Detailed demographic data, medical history and current medications, age, gender, ethnicity, type and duration of diabetes, co-morbidities, height, weight, blood pressure, HbA1c, lipids and renal function were documented. Other common causes of neuropathy were excluded based on a family history as well as testing for serum B12, folate, immunoglobulins, electrophoresis and anti-nuclear antibody. Participants underwent assessment of small and large nerve fibres using corneal confocal microscopy, nerve conduction studies and thermal thresholds along with assessment of HRDD. Visual analogue scale (VAS) pain scores (0–100) recording current, average and maximum pain ratings over the previous 24 h were documented. Patients were stratified into painful (DPN+) and painless (DPN-) cohorts based on the Toronto consensus that “the symptoms are distal, symmetrical, often associated with nocturnal exacerbations, and commonly described as prickling, deep aching, sharp, like an electric shock, and burning with hyperalgesia” for greater than 3 months, consistent with the requirement of pain chronicity defined by the International Association for the Study of Pain (IASP) [Patients with painful diabetic neuropathy (n (IASP) . All patNerve conduction and H-reflex studies were performed using a DANTEC Keypoint system . Participants were sat semi-recumbent at 45° with limb temperature maintained between 32–35°. Sural sensory amplitude (SNAP) and conduction velocity (SNCV) along with peroneal motor nerve amplitude (PMNAP) and conduction velocity (PMNCV) were recorded. For H-reflex studies, tibial nerve stimulation was performed using 1 ms square wave monophasic pulses delivered using surface silver-silver chloride electrodes to the popliteal fossa. Surface silver-silver chloride recording electrodes with a diameter of 9 mm were placed on the long axis of soleus. H-reflex recruitment curves were obtained to determine peak-peak H-reflex maximal amplitude (Hmax) by incrementing stimulation current by 1 mA. A minimal stimulation interval of 10 s was observed. For HRDD, a submaximal stimulus strength (to achieve a response of 75% of max) was used. A train of 10 stimuli were delivered  at 0.3, 2)), corneal nerve fibre length  (mm/mm2) and corneal nerve branch density ) were quantified. Participants underwent corneal confocal microscopy (CCM) using a laser scanning corneal confocal microscope HRT III  for both eyes using an established protocol . Six imaStatistical analyses were performed using GraphPad Prism statistical software . Parametric data were analysed using unpaired t-test or one-way ANOVA followed by Tukey’s multiple comparison to compare means between groups. Non-parametric data were analysed using the Kruskal–Wallis test followed by Dunn’s post hoc for multiple comparisons. The analysis of covariance (ANCOVA) (post hoc least significant difference (LSD)) was used to compare variables between groups, while statistically controlling for the effects of age. Receiver operating characteristic (ROC) curve analyses were used to define the Wilson/Brown estimate of area under the ROC curve. Optimal cut offs were determined using Youden’s index  and assoClinical and demographic characteristics are summarised in p = 0.006; H3, p ≤ H5, p ≤ 0.001; H6, p ≤ 0.016) and train averages  between patients with and without painful neuropathy. At 1, 2 and 3 Hz (p < 0.001 except for H2 at both 2 Hz (p < 0.034) and 3 Hz (p < 0.001)). There was a significant difference between patients with painful neuropathy and control subjects at 1Hz , 2 Hz  and 3 Hz . A significant difference was observed between patients without painful neuropathy and controls for H2 at 0.5 Hz (p = 0.037) and at individual stimulus responses towards the end of the train  and whole train average  at 1 Hz. No significant difference was seen between patients without painful neuropathy and control subjects at 2 or 3 Hz. To explore the time course of HRDD during stimulation trains in patients with diabetes and control subjects, analysis of individual stimulus responses and train averages was performed at five stimulation frequencies . There wand 3 Hz , Table 2To determine the optimal cut-off for HRDD between patients with and without pain, a ROC curve analysis was undertaken for both individual stimulus responses and average stimulus responses at 1, 2 and 3 Hz . The WilWe have previously demonstrated attenuated or enhanced HRDD in patients with diabetes and painful or non-painful neuropathy, respectively ,15. In tHRDD refers to the degree of suppression of the H-reflex by repetitive stimulation and increases in magnitude with increasing stimulation frequency . In addiIn the current study, patients with diabetes were segregated based on the presence and duration of characteristic neuropathic symptoms into those with pain versus those with no pain ,22. It s2A receptors [Our working hypothesis is that patients identified using this cut off may constitute a sub-group of patients in whom treatment with spinally acting medication is likely to be more effective. In our previous work in rodent models of diabetes, spinally administered Duloxetine, a serotonin-noradrenaline reuptake inhibitor (SNRI) thought to act by enhancing spinal inhibition via 5-HTeceptors , was shoeceptors . Indeed,eceptors ,25,26. OWhilst it may result in a proportion of patients with spinal disinhibition being missed, selecting a high specificity value—and thus a high likelihood of only including patients in whom impaired spinal inhibitory processes are a primary pain mechanism—would be beneficial for enriching clinical trial populations, assessing mechanism-based treatment of painful diabetic neuropathy, and as a component of studies involving deep phenotyping of pain ,28. For A- and GABAB-mediated responses [B mediated inhibition appears to compensate for the reversal in polarity of GABAA. GABAB receptor-mediated hyperpolarisation, in contrast to the fast inhibitory signalling mediated by GABAA receptors, is slow and prolonged [B-mediated hyperpolarisation that takes time to develop during the stimulus train. Whilst shorter stimulus trains are appropriate, and likely to be more clinically acceptable, for detecting impairment in HRDD in painful diabetic neuropathy, they may miss the enhancement of HRDD seen in patients with diabetes who have no pain. Our recent study suggested that HRDD, and by implication spinal inhibition and pain suppression, may be enhanced in patients with painless diabetic neuropathy . In the esponses . Initialrolonged . TherefoPotential limitations of the study include the relatively small cohort of patients and the fact that a proportion of patients in the painful diabetic neuropathy group were taking anti-neuropathic pain medication. Furthermore, patients were taking a variety of different anti-neuropathic pain medications (see results) with diverse mechanisms of action, precluding a systematic assessment of their effects on HRDD. It is currently not known whether anti-neuropathic pain medication affects HRDD. One further potential limitation of the study is that the control group was of significantly lower age than both the painful and painless diabetic neuropathy groups. It should be recognised, however, that our previous studies showed no significant correlation between HRDD and age. It also does not affect the ROC analysis as data from control participants was not used for this analysis. The current study provides a detailed comparison between individual and average HRDD stimulus responses to distinguish patients with painful diabetic neuropathy, specifically those whose pain is likely driven by spinal disinhibition. An average of responses H2–5 provided good to excellent predictive ability at all three frequencies, with 1 Hz proving optimal. In terms of clinical utility, the shortened train of five stimuli combined with a moderate stimulation frequency of 1 Hz makes HRDD a valuable tool which can easily be accommodated in a clinical setting in terms of equipment, time and most importantly patient tolerability. Longer trains may be required to investigate enhanced inhibitory processing in the spinal cord in painless diabetic neuropathy.


Background: Approximately half of all patients who undergo surgical repair of extremity fractures report persistent postsurgical pain (PPSP) at 1-year post-surgery. Psychological factors such as anxiety, depression, catastrophization, poor coping, high somatic complaints, and pessimism about recovery are risk factors for the development of PPSP. It is possible that interventions such as cognitive behavior therapy (CBT) that target psychological factors may reduce the incidence of PPSP in this population.Aims: The current report reviews the role of psychological factors in the development of PPSP and discusses the rationale and protocol development for a multi-site randomized-controlled trial investigating the effectiveness of CBT in reducing PPSP in patients with surgically treated extremity fractures. Anxiety, depression, pain catastrophizing  Questionnaire to identify unhelpful illness beliefs that are predictive of poorer outcomes (pain and function) postfracture. This 27-item questionnaire assesses four domains: somatic complaints , coping , energy (“Have you been feeling low in energy and slowed down during the past week?”), and optimism (“Have you felt that you could not overcome your difficulties during the past week?”). Higher scores on the SPOC Questionnaire are indicative of high somatic complaints, low energy, poor coping, and pessimism about recovery.28 Scores on the SPOC questionnaire at 6 weeks postsurgery have been shown to be more strongly predictive of physical and emotional functioning, unemployment, and quality of life at 1 year postsurgery than other known risk factors for the development of PPSP such as gender, site and severity of the fracture, smoking status, type of fixation, and whether or not the injury was work related.30Busse et al.30 Patients who had high SPOC scores at 6 weeks postsurgery were seven times more likely to report PPSP and ten times more likely to endorse pain interference at 1 year postsurgery compared to patients with low SPOC scores at 6 weeks post tibial fixation.30 In another study of 1560 patients undergoing surgical fixation for an extremity fracture, patients with high SPOC scores at 6 weeks postsurgery were six times more likely to report persistent pain and at least moderate levels of pain interference at 1 year postsurgery compared to patients with low SPOC scores.29 As such, the beliefs that patients hold about their pain and recovery process appear to have a powerful effect on outcome and suggest the possibility that patients with fractures who exhibit unhelpful illness beliefs can be identified and targeted for concurrent therapy designed to modify such cognitions and improve prognosis.In a study of 267 patients undergoing traumatic tibial fracture repair, the rates of PPSP at 1 year postsurgery were 37.6% for patients with low SPOC scores at 6 weeks postsurgery, 54.1% for patients with intermediate SPOC scores at 6 weeks postsurgery, and 81.6% for patients with high SPOC scores at 6 weeks postsurgery.32 Most CBT protocols include some combination of psychoeducation, goal-setting, relaxation strategies, cognitive restructuring , problem solving, time-based pacing, communication strategies, and relapse prevention. More recently, there has been increasing interest in the utilization of CBT during the perioperative period as a strategy to decrease the risk of developing PPSP. A recent meta-analysis of 15 randomized controlled trials investigating the effectiveness of perioperative psychotherapy for patients undergoing a variety of surgical interventions found that patients who received active psychological interventions  had significantly less persistent pain and physical impairment at 3- to 30-month follow-up compared to patients who received treatment as usual.33 Notably, just receiving education about coping strategies with no active psychological intervention did not affect the severity of persistent pain or physical impairment at follow-up (test of interaction P = 0.01 for both outcomes).Cognitive behavioral therapy (CBT) is a first-line psychological treatment for patients with chronic pain that focuses on the interrelationship between cognitions, emotions, physical sensations, and behaviors to understand and address patients’ current difficulties with a focus on helping patients learn new skills and strategies to cope with their chronic pain and to modify maladaptive cognitive and behavioral responses to chronic pain.33 No studies have examined the effects of CBT in the reduction of PPSP in surgically managed acute closed or open extremity fractures. This is an important area for investigation because acute closed or open extremity fractures differ from joint replacement in a number of ways, including the sudden onset of the fracture and necessity for immediate surgical management, high rate of traumatic mechanisms of injury , and often inexperience with ill health due to the relatively young mean age of occurrence.30Looking specifically at the effects of CBT and relaxation strategies for reducing PPSP following orthopedic surgeries, studies to date have solely focused on hip and knee replacements.Cognitive Behavioural Therapy to Reduce Persistent Post-Surgical Pain Following Internal Fixation of Extremity Fractures (COPE) study was developed to examine the efficacy of CBT in the reduction of PPSP and disability in patients undergoing fixation of extremity fractures. This is a multisite randomized controlled trial that will recruit 1000 adult patients undergoing fixation surgery for an acute closed or open extremity fracture across approximately 15 clinical sites in Canada and, potentially, The Netherlands.The Inclusion criteria will be as follows: (1) males and females aged 18 years or older; (2) acute open or closed fracture of the appendicular skeleton; (3) fracture treated operatively with internal fixation; (4) screened for eligibility within 6 weeks of fracture; (5) cognitive ability and language skills to participate in CBT; and (6) able to start CBT within 8 weeks of fracture. Exclusion criteria will include (1) fragility fracture, (2) stress fracture, (3) concomitant injury that is likely to impair functioning for as long as or longer than the extremity fracture, (4) active psychosis, (5) active suicidality, (6) active substance use disorder, (7) already participating in or planning to start a psychological treatment within the duration of the study , (8) anticipated problems with partaking in the CBT sessions or completing follow-up appointments , and (9) incarceration.34 and that online CBT is effective for chronic pain.35 As such, allowing participants the option of selecting between online and telephone CBT will increase the accessibility and feasibility of the study. Patients will complete follow-up assessments of pain intensity, pain interference, and physical and emotional functioning at baseline (4–8 weeks postfracture) and 3, 6, 9, and 12 months postsurgery. The statistical analysis plan is detailed in the Appendix.Patients will be randomized to one of two treatment arms: (1) CBT or (2) care as usual. Randomization will be stratified by clinical site, sex, fracture type (open or closed), and illness beliefs (SPOC score ≥ 48 versus SPOC score < 48). Patients randomized to psychotherapy will be able to select between six sessions of telephone CBT (1-h sessions) or 6 weeks of online CBT with asynchronous communication with a therapist. Both CBT interventions will follow the same treatment protocol. The rationale for including a choice of online or telephone CBT was guided by preliminary challenges in recruiting participants for face-to-face CBT due to scheduling and transportation difficulties and evidence that online or telephone-administered CBT is equally effective to in-person CBTThe CBT protocol is outlined below, including the rationale for inclusion of different components of the protocol. Although the current protocol includes a number of components that are included in standard chronic pain protocols, the presentation of the components in the current study differs because the focus is on individuals at risk for development of chronic pain. Thus, the emphasis is on prevention and addressing vulnerability factors, including beliefs about pain and fear of movement, that may play a role in the development of PPSP.36 Relaxation strategies (diaphragmatic breathing) will be presented as a tool to manage pain flares and stress related to the recovery process. Participant values and goal-setting using the SMART goal formula  will be included to identify values-based actions that the participant can partake in postinjury to build hopefulness rather than focusing on losses and what the participant is unable to do postinjury.Week 1 will provide an introduction to the principles of CBT (module 1), pain education (module 2), relaxation strategies (module 3), and goal-setting (module 4). Education about the nature of pain will discuss differences between acute and chronic pain, psychological factors that contribute to the transition from acute to chronic pain, the gate control theory of pain, and the role of central sensitization in chronic pain. The goal of pain education is to provide a better understanding of the complex nature of pain and a rationale for the different strategies that will be taught throughout the treatment program, including the importance of self-management strategies in the recovery process. Research evidence in chronic musculoskeletal pain has shown that pain neuroscience education reduces pain intensity, improves functioning, decreases disability, and decreases pain catastrophizing.30 Participants’ responses on the four domains of the SPOC questionnaire will guide the cognitive restructuring, particularly identifying and modifying unhelpful beliefs related to the pain experience and ability to cope with the recovery process.Discussion of the CBT model and the interconnectedness of thoughts, emotions, behaviors, and physical sensations in the experience of pain (module 5) and introduction to cognitive restructuring (module 6) will occur in week 2. Cognitive restructuring is a CBT strategy that is aimed at identifying negative automatic thoughts and relevant cognitive distortions  and learning strategies to generate more balanced/helpful thoughts. The aim of cognitive restructuring is to teach a strategy to address unhelpful illness beliefs that are associated with the development of PPSP.37 As such, week 3 will focus on identification of any avoided and/or feared movements or activities that have been deemed as safe and engagement in gradual exposures to the feared/avoided movements or activities, noting anxious predictions, actual outcomes, and learning. The goal of the exposures is for participants to acquire accurate data as to the “danger” of activities or movements and to learn that if they do experience pain with the activity or movement, they are able to cope with it. Therapists will be in contact with other members of the participants’ health care team  as needed during this week.Week 3 will provide an introduction to the fear avoidance model and modification of behavioral responses to pain (module 7). The fear avoidance model states that recovery following an injury follows one of two pathways depending on the interpretation of pain. If pain during the recovery process is interpreted as a nonthreatening normal part of recovery, then there is a gradual return to normal activities. On the other hand, if pain during the recovery process is interpreted as threatening and dangerous, then anxiety and fear develop, leading to avoidance of activities and disuse of the affected limb and a prolonged pain experience.38 Time-based pacing will be introduced as another strategy to help with engagement in feared activities/movements and accomplishing SMART goals. The goal of time-based pacing is to provide a starting point for engagement in activities and to gradually increase activity time as strength and stamina increase. The discussion about managing pain flares will include a normalization of the experience of pain flares throughout the recovery process and discussion of strategies for managing pain flares .An introduction to time-based pacing (module 8) and managing pain flares (module 9 and 10) will occur in week 4. Time-based pacing, a self-management strategy that is commonly used in chronic pain to address under- and overactivity, focuses on using behaviors such as breaks and switching tasks in a quota-contingent manner  rather than in a pain-contingent manner  in order to increase functioning despite the pain.Week 5 will provide an introduction to mindfulness and acceptance (module 11), pain medications (module 12), and managing setbacks (module 13). When recovering from surgery, there is often a tendency to judge pain and progress negatively, which can lead to further negative emotions and a worsening of the pain experience. The concepts of mindfulness and acceptance and practicing of the body scan aim to help participants accept the present moment and to place more energy and focus onto what they can control in their recovery process rather than placing time and energy into negative emotions and what they cannot control. Week 5 will also include a discussion about use of pain medications and, if appropriate, will help participants prepare for any necessary discussions with their family physician around their use of pain medications.Summarizing and preparing for the future (module 14) will take place in week 6. Participants will have an opportunity to reflect on the strategies and changes they have made throughout the 6-week program and to identify next steps with regards to maintaining and progressing forward on gains.Therapists will have access to optional modules that include problem solving, sleep hygiene, and further relaxation strategies  that they can use as needed with patients .Given the growing evidence that patients’ beliefs and emotional functioning play an important role in the development of persistent pain after fracture repair, research that investigates potential interventions for the reduction of PPSP is urgently needed, especially in high-risk populations. The proposed study will be the largest and only multisite study to date on the efficacy of CBT in the prevention of PPSP after extremity fracture repair. The results of this study may have significant implications for the implementation of interventions targeting beliefs and coping strategies to reduce the onset of persistent pain in patients with surgically managed extremity fractures.


As telecommunication technologies advance, efforts are being made to mitigate direct patient contact in the COVID-19 pandemic due to the risk of contagion. The ability to host telephone and video visits within patient portals within health care institutions will only become increasingly valuable. Neck pain, a common complaint seen in primary care clinics, is well-suited to telemedicine evaluation, as related etiologies are often comparatively straightforward. A good assessment of the cervical spine by telephone or video is possible with the right knowledge and practice.The purpose of this article is to propose questions and maneuvers that can be used to evaluate the cervical spine via telephone or video, as well as likely diagnoses that can be reached through these.Phone and video evaluation of the cervical spine can result in valuable data regarding symmetry, range of motion, functional movement patterns, modified strength testing, and provocative testing. The skill set necessary to do telephone and video visits should be included in the curriculum of physician learners. Neck pain is among the most frequent complaints of patients seen in primary care clinics . There aThe goal of this article is to discuss how patients with neck pain can be evaluated using telephone and video visits and the specific details that need to be considered during these visits. While limitations exist, we believe that the use of telecommunication technologies to accurately evaluate and diagnose patients is possible.Telecommunication and security technologies have become so advanced that it is possible to perform telephone and video visits within the patient portals that are tied to health care institutions . In all Neck conditions lend themselves to telehealth evaluation, as their etiologies are often more straightforward than those of conditions that affect other joints. Additionally, red flags are easily identified through verbal history taking, and physical examination of the cervical spine by video is easier than that of smaller joints, such as the hands and wrists, or of more complex joints, like the shoulder.As the availability of mobile applications increases, musculoskeletal evaluation by telemedicine will become accessible to a greater number of patients. The ability to connect with physicians through popular devices, such as a telephone or tablet, should only serve as an impetus to make telephone and video visits standard practice. This is likely to become a widely-used method for many patients with pain and disability, whether stemming from the cervical spine or from another source.Evaluation of neck pain via telephone visitAs an actual physical examination cannot be done by telephone, each question posed by the physician should be aimed at uncovering a suspected injury or condition in order to narrow the differential diagnosis quickly and concisely. Furthermore, each response should be taken in the context of the patient’s history. Table Evaluation of neck pain via video visitThe neck and shoulders should be examined for asymmetry. The examiner should pay attention to the patient’s head position in their natural neutral position. The patient should be asked to palpate around the neck: the patient can palpate the posterior midline , posterior paraspinal musculature, and anterior musculature Figure . The exaRange of motion tests should be performed next, and these can be quite easily estimated via video. Normal cervical flexion is about 50°; extension, 80°; right and left side bending, 45°; and right and left rotation, 85° Figure . Testing the entire neck range of motion  is important to avoid missing important conditions. The patient can be asked to place their own hand against their head to resist motion and to assess if this causes pain Figure . This maShoulder range of motion should also be evaluated Figure .Strength can be assessed by asking the patient to lift a weight, such as a dumbbell or a book, while they describe any ensuing pain or differences beyond what would be expected for hand dominance Figure . The patSigns of cervical nerve root irritation or impingement can be obtained with a forward flexion test: pain will be elicited when the patient is asked to turn their head to the side and then flex their neck forward Figure . The patTelephone and video visits should be considered important options for the evaluation of musculoskeletal conditions, such as neck pain. Patients with neck pain may have difficulty turning their heads while driving or may be taking medications related to previous neck pain episodes that may cause drowsiness, making it difficult or dangerous for them to travel or operate motor vehicles, and making virtual evaluation a valuable option. Previous literature has reported the use of telehealth visits prior to the COVID-19 pandemic for patients living in rural areas and for those who are older, blind, or disabled .While telephone and video visits have their limitations, they can allow for the evaluation and accurate diagnosis of patients with neck pain. Questions and instructions can be given by telephone, and patient responses can give clinicians an idea of the etiology of the neck pain. Guided palpation is important, as is the patient’s ability to perform certain movements, such as the thumbs-up or “OK” signs. Telephone and video visits may become valuable options for many patients with pain and disability, whether stemming from the cervical spine or from another source. The skill of managing telephone and video visits should be taught to physician learners as alternatives for future encounters. Scheduling these visits will likely continue, even after the resolution of the COVID-19 pandemic.


Fibromyalgia is a syndrome characterized by chronic and widespread musculoskeletal pain, often accompanied by other symptoms, such as fatigue, intestinal disorders and alterations in sleep and mood. It is estimated that two to eight percent of the world population is affected by fibromyalgia. From a medical point of view, this pathology still presents inexplicable aspects. It is known that fibromyalgia is caused by a central sensitization phenomenon characterized by the dysfunction of neuro-circuits, which involves the perception, transmission and processing of afferent nociceptive stimuli, with the prevalent manifestation of pain at the level of the locomotor system. In recent years, the pathogenesis of fibromyalgia has also been linked to other factors, such as inflammatory, immune, endocrine, genetic and psychosocial factors. A rheumatologist typically makes a diagnosis of fibromyalgia when the patient describes a history of pain spreading in all quadrants of the body for at least three months and when pain is caused by digital pressure in at least 11 out of 18 allogenic points, called tender points. Fibromyalgia does not involve organic damage, and several diagnostic approaches have been developed in recent years, including the analysis of genetic, epigenetic and serological biomarkers. Symptoms often begin after physical or emotional trauma, but in many cases, there appears to be no obvious trigger. Women are more prone to developing the disease than men. Unfortunately, the conventional medical therapies that target this pathology produce limited benefits. They remain largely pharmacological in nature and tend to treat the symptomatic aspects of various disorders reported by the patient. The statistics, however, highlight the fact that 90% of people with fibromyalgia also turn to complementary medicine to manage their symptoms. Fibromyalgia (FM) is a syndrome characterized by chronic musculoskeletal pain. The main symptoms of this disease are muscle stiffness, joint stiffness, insomnia, fatigue, mood disorders, cognitive dysfunction, anxiety, depression, general sensitivity and the inability to carry out normal daily activities ,2. FM caThe pathophysiological factors of FM are not yet well known and continue to be the focus of much research. FM appears to be related to a pain-processing problem in the brain. In most cases, patients become hypersensitive to pain. The constant hypervigilance to pain can also be associated with psychological problems .The main alterations observed in FM are dysfunctions in mono-aminergic neurotransmission, leading to elevated levels of excitatory neurotransmitters, such as glutamate and substance P, and decreased levels of serotonin and norepinephrine in the spinal cord at the level of descending anti-nociceptive pathways. Other anomalies observed are dopamine dysregulation and altered activity of endogenous cerebral opioids. Taken together, these phenomena seem to explain the central physiopathology of FM .Over the years, peripheral pain generators have also been recognized as a possible cause of FM. In this case, patients manifest symptoms such as cognitive impairment, chronic fatigue, sleep disturbances, intestinal irritability, interstitial cystitis and mood disorders ,15.Peripheral abnormalities may contribute to increased nociceptive tonic supply in the spinal cord, which results in central sensitization. Other factors that appear to be involved in the pathophysiology of FM are neuroendocrine factors, genetic predisposition, oxidative stress and environmental and psychosocial changes ,17.FM appears to be more common in women than men for the following reasons: higher levels of anxiety and depression, altered behavior in response to pain, altered CNS input and hormonal effects related to the menstrual cycle .As mentioned above, FM is considered a central sensitivity syndrome. Central sensitization refers to a neuronal signal amplification mechanism within the central nervous system that leads to a greater perception of pain . For thi+ channels, while no effect was observed with NSAIDs [Patients with FM present a lower pain threshold that generates a condition of diffuse hyperalgesia and/or allodynia. This indicates that there may be a problem with the amplification of pain or with sensory processing in the CNS. These FM phenomena have been confirmed in clinical studies that used functional neuroimaging or measured alterations in neurotransmitter levels that influence sensory transmission and pain ,26,27. Ih NSAIDs ,35,36.Clinical studies based on functional magnetic resonance imaging (fMRI) have confirmed a central neuronal alteration in nociceptive processes. In particular, following the same amount of pressure stimuli, patients with FM had greater neuronal activation in the pain-processing areas of the brain than control subjects ,38. In iThe use of fMRI has also been useful for examining the degree of connection between the various brain regions. This analysis has been applied to both resting and active individuals. The advantage of the analysis at rest is that it provides data on brain changes associated with ongoing spontaneous chronic pain. With this technique, individuals with FM were shown to have greater connectivity between a network called “default mode” (active when the brain is at rest) and the insula (pro-nociceptive region) . The deg2+ channels [2+ channels may mediate some of these changes. Therefore, the animal models studied show that alterations in central excitability occur throughout the nociceptive system, from the spinal cord to the cortex.Furthermore, pregabalin has been observed to reduce glutamatergic activity in the insula and functional connectivity between the default mode network and the insula in patients with FM . Anotherchannels . This laAlthough FM is thought to be a central pain disorder, many studies have shown peripheral nerve changes in patients with FM. In particular, people with FM have been reported to have a reduced number of epidermal nerve fibers in skin biopsies ,73,74,75In humans, the intramuscular injection of an acid solution into the anterior tibial muscle induces muscle pain both at the site and in the ankle, producing primary and secondary hyperalgesia . TherefoHowever, it has been shown that an ASIC antagonist administered after the onset of hyperalgesia has no positive effect. This indicates that once hyperalgesia has developed, it is independent of the activation of nociceptors due to acid pH ,91. In cThe release of substance P from nociceptive nerve fibers and the activation of its neurokinin 1 receptor (NK1), which is found post-synaptically in the spinal dorsal horn, as well as on immune cells, smooth muscle, blood vessels and other peripheral cells, seem to play an important role in the transmission of pain signals . SubstanAs previously mentioned, the chronic pain typical of FM is due to alterations in central and peripheral sensitization. Over the years, researchers have searched for biomarkers that are capable of detecting these changes. In particular, they focused on factors capable of acting on the growth and survival of nerve cells, such as nerve growth factor (NGF). This factor is indeed involved in promoting the growth, proliferation and survival of sensory neurons that transmit pain, temperature and tactile sensations .Data obtained in earlier studies showed an increase in NGF in the cerebrospinal fluid of FM patients . HoweverIncreasing evidence indicates that neurogenic-derived inflammatory processes occurring in the peripheral tissues, spinal cord and brain are also responsible for the pathophysiology of FM ,102,103.Studies conducted in patients have confirmed that inflammation is involved in FM. Indeed, FM patients have been shown to have enhanced circulating inflammatory cytokines and inflammatory cytokines released by circulating immune cells ,105.Kadetoff et al. described an increased concentration of IL-8 in the cerebrospinal fluid of FM patients compared to healthy subjects . This fiFinally, a study by Smart et al. described a subgroup of fibromyalgia patients characterized by ANA (anti-nuclear antibody) positivity, with the speckled pattern clearly predominating. The use of the Smart Index, which corrects the erythrocyte sedimentation rate value in relation to age, revealed that ANA-positive FM patients had a more pronounced inflammatory response profile than the ANA-negative subgroup, suggesting that autoimmunity potentially contributes to sub-inflammatory fibromyalgia . SLC64A4) and the transient receptor 2 potential vanillic channel gene (TRPV2) are the major genes responsible for pain susceptibility in FM [SLC64A4 is characterized by a single nucleotide polymorphism and is associated with chronic pain conditions , as well as increased levels of depression and psychological disorders related to an alteration in serotonin reuptake [TRPV2 gene is expressed in mechano- and thermo-responsive neurons in the dorsal root and trigeminal ganglia and appears to be responsible for reducing the pain threshold in FM patients [rs11127292 in a gene similar to myelin transcription factor 1 (MYT1L), which is responsible for neuronal differentiation and involved in cognitive alterations. The second is an intron copy number variable in the neurexin 3 (NRXN3) gene, which normally acts as a receptor and cell adhesion molecule in the nervous system, and variations in this gene are involved in autism spectrum disorder [TAAR1 gene, which mediates the availability of dopamine, whose reduction can increase the sensitivity to pain typical of FM [RGS4, which is expressed in the dorsal horn of the spinal cord, the locus coeruleus and the nuclei of the bed of the stria terminalis, and is responsible for modulating the descending inhibition of pain perception [CNR1, which encodes the cannabinoid receptor CB-1 [Over the years, studies have shown the potential involvement of genetic factors in the onset of FM ,118. Linty in FM . SLC64A4reuptake . The TRPpatients . Other gpatients . Therefodisorder . Other ral of FM . Anothertor CB-1 ,129. Anotor CB-1 . Taken tThe role of stress in the exacerbation of fibromyalgia symptoms has been widely described from an epidemiological point of view through both self-reports and clinical questionnaires. On the basis of these data, the hypothalamic–pituitary–adrenal axis, central to the stress response, was examined. Despite the discrepancy between different studies on possible alterations in plasma cortisol levels in FM patients, dysregulation of its circadian variation is frequently observed. In particular, flattening of the plasma cortisol concentration curve was observed during the day: this seems to manifest itself through a milder and more gradual descent compared to the morning peak of maximum concentration or through a lowering of the peak itself ,134,135.A patient study looked at levels of corticotropin-releasing factor (CRF) in cerebrospinal fluid (CSF), heart rate variability (HRV) and pain symptoms  in subjects with FM. The results obtained in this study showed that CRF levels were associated with sensory and affective pain symptoms but not with symptoms of fatigue. Furthermore, an increase in HRV was associated with an increase in CRF and pain in patients with FM. These results were subsequently adjusted for age, sex and depressive symptoms, and a correlation between CRF levels and sensory pain symptoms was confirmed. Another important finding was that women with FM and self-reported histories of physical or sexual abuse did not have increased levels of CRF in their CSF. This indicates that there may be subgroups of FM patients with different neurobiological characteristics. Therefore, further studies are needed to better understand the association between CRF and pain symptoms in FM . In anotHowever, to date, the results regarding the involvement of the HPA in the pathophysiology of FM have been conflicting, and new studies will be needed in the future to fully clarify this aspect . FurtherThe possible pathogenetic role of the growth hormone (GH)/insulin-like growth factor 1 (IGF-1) axis was also investigated. Several studies have found that about one-third of individuals with fibromyalgia have lower IGF-1 levels than control groups . Serial As previously highlighted, psychiatric comorbidities in fibromyalgia constitute a relevant aspect of the disease, and a close correlation between stress and fibromyalgia symptoms has been described several times. According to several studies, the prevalence of psychiatric comorbidities, such as anxiety disorders and depression, among patients with this pathology reaches 60% in certain subpopulations . The preSleep disorders are classically described within the symptomatic process of fibromyalgia. However, some recently reported data have generated the hypothesis that such disorders may be included among the causative factors of this pathology, rather than among its manifestations. Studies published in recent years have described a bidirectional correlation between sleep disturbances and widespread musculoskeletal pain, and it even seems that insomnia tends to precede the onset of pain and has predictive value regarding its onset and its persistence ,163. StuFindings in human studies carried out through the application of evoked potentials indicate that increased nociceptive sensitivity in response to sleep deprivation could derive from dysregulation of the descending pathways of pain control or from cognitive amplification of the central origin, thus excluding the mechanism of sensory amplification . BiochemPeripheral impulses are transmitted to the central nervous system by myelinated Aδ and unmyelinated C fibers. Pain signals travel through Aδ fibers very rapidly (~10 m/s) to the central nervous system, while those mediated by C fibers travel relatively slowly (~1.6 m/s) . NumerouIn addition, animal studies have shown that this nervous system can modulate both peripheral neurons and innate immune cells, keratinocytes and dendritic cells by overexpressing α1-adenoreceptors ,191. TheOther findings that have been observed in approximately 50% of FM patients are abnormalities in the morphology, neurophysiology or function of both myelinated small Aδ fibers and unmyelinated C fibers ,75. ThesFurthermore, in vivo, a decrease in the density of peripheral nerve fibers of the hind leg was demonstrated in a rat model of FM, which was induced by increasing glutamate levels . This shThe diagnosis of FM is currently based only on a complete clinical evaluation; until 2010, it relied on the 1990 ACR criteria  of widesThe prevalence of fibromyalgia in family clusters and several studies supports the theory that genetic factors, in conjunction with environmental causes such as trauma, illnesses or emotional stress, could predispose individuals to FM. Key gene polymorphisms that are regarded as risk factors for fibromyalgia are those that are involved in mood disorders, although some findings are controversial. These candidate genes include the serotonin transporter (5-HTT), the serotonin 2A (5-HT2A) receptor, catechol-O-methyltransferase (COMT) and the dopamine receptor. A higher frequency of the S/S genotype of the 5-HTT gene was observed in FM patients compared to in healthy subjects . HoweverTAAR1), the G protein signal 4 regulator gene (RGS4), the cannabinoid receptor 1 gene (CNR1) and the ionotrophic glutamate receptor gene AMPA 4 (GRIA4) [Other genes that have been associated with FM and that regulate nociceptive and analgesic neuronal pathways are the receptor 1 gene ( (GRIA4) . SLC64A4, TRPV2, MYT1L and NRXN3 are possible candidate genes found to be related to fibromyalgia. The frequency of polymorphisms in selected metabolism genes such as CYP P450 in FM pathology was also reported in another study [Genome-wide association studies aiming to identify genes potentially involved in the pathogenesis of fibromyalgia have reported that genetic factors may be responsible for up to 50% of vulnerability to the disorder. er study .In addition, a gene–environment association involving epigenetic changes was suggested as a triggering mechanism: fibromyalgia appears to be particularly characterized by a hypomethylated DNA pattern in genes involved in the stress response, DNA repair, the autonomic system response and subcortical neuronal abnormalities. In multiple tissues, differences were observed in the genome-wide expression profile of microRNAs, suggesting the involvement of various processes in the pathogenesis of fibromyalgia. Single nucleotide polymorphisms (SNPs) have been identified as possible candidates that are directly linked to FM susceptibility. BDNF, NAT15, HDAC4, PRKCA, RTN1 and PRKG1 genes were mapped to differently methylated sites, indicating the potential involvement of FM nervous system development, skeletal/organ system development and chromatin compaction pathways. Differentially methylated sites that correlated with the FM map were frequently identified in genes involved in biological functions such as DNA repair, immune response and membrane transport genes.Previous studies have shown that early life experience and environmental factors in general may modulate genome function and the phenotype through epigenetic mechanisms without changing the DNA sequence . In chroAt least 30 percent of human genes are regulated by microRNAs , each ofArgonaute proteins may be packaged with miRNAs in exosomes and transported in biological fluids. In chronic pain conditions, miRNAs were observed to play a fundamental role , in whicA genome-wide expression profile analysis of microRNAs in the CSF of females with FM  demonstrThese polymorphisms are also correlated with psychiatric conditions; thus, they may be linked to psychiatric comorbidities instead of fibromyalgia alone. In addition, genetic findings are always ambiguous, and fibromyalgia has not been closely related to any single candidate gene.IL10, IL25 and 1L36A) [SLC1A5 and SLC25A22, which encode glutamate transporters in the CNS [GRM6) gene encoding the group III G protein-coupled receptor, which is associated with the inhibition of the cyclic AMP cascade and involved in neuropathic pain signaling in dorsal horn neurons, was also upregulated [Since gene expression is modulated by epigenetic pathways, studies have compared transcriptional changes between FM patients and controls. A previous study identified 482 genes differentially expressed between patients and healthy controls, and the results indicated a relationship between FM status and the upregulation of inflammatory cytokine genes (d 1L36A) . In addi the CNS . In FM segulated . The altegulated ,242 may It is important to note that the endogenous opioid system is similar to the immune system due to the presence of opioid receptors on the lymphocyte membrane. Among these receptors, the Mu-opioid receptor on B lymphocytes has been proposed as a specific biomarker for FM patients. The results obtained from a recent study showed a lower percentage of Mu-positive B cells in subjects with FM than in controls. Therefore, this receptor could be used as a biomarker for the objective diagnosis of patients who report chronic pain, such as that perceived by patients with FM .There is considerable interest in using a simple blood test to diagnose fibromyalgia. Therefore, several attempts have been made to detect unique serological markers. These findings, as well as those of genetic testing, are frequently contradictory, and no clinical tests have yet been confirmed to date .The association between antipolymer antibody (APA) and fibromyalgia was assessed because APAs were present in the serum of women with fibromyalgia-like signs . One stuNeuropeptide Y has been shown to both decrease and induce pain. Crofford and his colleagues were the first to test plasma neuropeptide Y levels in patients with fibromyalgia and found that they were substantially lower in the analyzed patients than in normal subjects . These rSome studies have also indicated the involvement of BDNF in pain syndromes . Based oCompared to healthy controls, fibromyalgia patients displayed higher levels of glutamate compounds in the right amygdala, and pain was associated with elevated levels of glutamate in the left thalamus . These rCytokines have been suggested to be involved in fibromyalgia syndrome, but the findings tend to be controversial, particularly because there have been reports of increases, decreases and no substantial changes. It has been repeatedly shown that IL-8, a pro-inflammatory cytokine, is increased in fibromyalgia patients. Given that IL-8 promotes sympathetic pain, it may play an important role in the frequency of pain in fibromyalgia. The IL-8 expression pattern could aid in the diagnosis of fibromyalgia and in effective treatment strategies if confirmed in further studies . 2+ homeostasis, cell migration, inflammation and defense against oxidative cell damage [It has become generally accepted in the last few years that the genome represents only the first layer of complexity. Biological functions are dependent on a complex protein population, and protein characterization can reveal posttranslational changes  and provide insight into protein–protein interactions and functions. For this reason, the field of proteomics, which is the identification of proteins in biological samples such as body fluids and tissue extracts, is receiving growing interest. Whole saliva analysis was performed to measure the protein content and to evaluate quantitative or qualitative differences between patients with fibromyalgia and healthy subjects . For exal damage . Transall damage . Researcl damage . These pl damage . Combinil damage .1H NMR metabolomics examination of urine samples, a group of clinically well-defined female FM patients with no psychiatric co-morbidities could be completely distinguished from a group of young healthy women [In an untargeted hy women . The prehy women . HoweverFibromyalgia patients produce higher levels of harmful free radicals than healthy people and have a decreased antioxidant ability, contributing to oxidative stress. Compared to other areas of the body, the central nervous system is highly susceptible to ROS because of its high lipid content . The proFM is a complicated syndrome characterized by chronic pain, joint rigidity, fatigue, sleep interruption, cerebral dysfunction and depression. Research on FM is becoming progressively more significant because of the compromised quality of life of patients and the economic weight on the medical care system. The pathogenesis of fibromyalgia is not well known, and the diagnosis is only clinical at present. Oxidative stress, mitochondrial dysfunction, multivitamin deficiencies and a disproportion between oxidants and antioxidants are interesting and clinically attractive topics that require further study to clarify the state and development of FM.To date, no objective tests or biomarkers with sufficient diagnostic accuracy have been identified, and current analyses can only indicate a predisposition to fibromyalgia. Numerous studies, however, provide insights into the pathophysiology of fibromyalgia. Proteomic research as well as gene expression profiling may have potential applications as novel methods for the diagnosis of FM. Pharmacological treatment alone is inadequate for the majority of patients who suffer from FM syndrome. Given the different mechanisms of pain sensitivity, treatments will continue to involve multidisciplinary programs that target the peripheral, central, cognitive-emotional and interpersonal causes of the chronic pain that characterizes FM pathophysiology.


However, evidence from low- and middle-income regions was insufficient, and whether the sensitivity to improvements differs between walk-in and emergency medical service (EMS)-transported patients remained unclear. In this study, we aimed to examine the association of chest pain center accreditation status with door-to-balloon (D2B) time and the potential modification effect of arrival mode. (2) Methods: The associations were examined using generalized linear mixed models, and the effect modification of arrival mode was examined by incorporating an interaction term in the models. (3) Results: In 4186 STEMI patients, during and after accreditation were respectively associated with 65%  and 71%  reduced risk of D2B time being more than 90 min (using before accreditation as the reference). Decreases of 27.88  minutes and 26.55  minutes in D2B were also observed for the during and after accreditation groups, respectively. The impact of accreditation on timeline improvement was greater for EMS-transported patients than for walk-in patients. (4) Conclusions: EMS-transported patients were more sensitive to the shortened in-hospital delay associated with the initiative, which could exacerbate the existing disparity among patients with different arrival modes. ST-segment elevation myocardial infarction (STEMI) is the deadliest and most time-sensitive acute cardiac event. Primary percutaneous coronary intervention (PCI) is the typically recommended treatment for STEMI cases. The door-to-balloon time, also referred to as the in-hospital delay, which denotes the interval from the patient’s arrival at the emergency department to the first inflation of an angioplasty balloon in the occluded coronary artery, is widely used to assess the timeliness of primary PCI . A door-A growing strand of studies indicate that accreditation of chest pain centers can facilitate the implementation of strategies to improve healthcare quality for STEMI. Accredited chest pain centers should follow the criteria according to the recommended guideline, accompanied with a number of quality improvement activities . For instance, the United States and Germany have witnessed improvements in the management and clinical outcomes of STEMI patients after an extensive adoption of nationwide programs for chest pain center professional society accreditation ,10,11,12(1)A discharged diagnosis of STEMI, according to ischemic symptoms, ECG, or positive cardiac markers;(2)Underwent primary PCI;(3)Arrived at hospital by either of arrival modes: directly by self or transported via EMS.For this study, we utilized data from all the accredited hospitals with PCI capabilities in Beijing during January 2016 to June 2019. For our study, we recruited STEMI patients who met the following criteria:N = 15), missing hospital arrival time, or implausible door-to-balloon time, such as a negative value or time exceeding 24 h (N = 37).Patients were excluded if they had an unknown mode of arrival , and signs and symptoms at presentation: whether the patient had sustainable chest pain (refers to the onset of chest pain that lasts more than 30 min and cannot be relieved by rest), intermittent chest pain (refers to chest pain that lasts a few minutes at a time and can be relieved by rest or elimination of the triggers), chest pain relief, abdominal pain, dyspnea, cardiogenic shock, heart failure, malignant arrhythmia, receiving prehospital cardiopulmonary resuscitation or not, heart rate (beats/min), blood pressure (mmHg), and Killip class (I to IV) . HospitaKruskal–Wallis test for continuous variables. Categorical variables are presented as counts and percentages. Quantitative variables are expressed as means ± standard deviations (SDs) or medians and interquartile ranges. p values of less than 0.05 were considered to indicate statistical significance. We describe the median of door-to-balloon times and the percentage of patients for whom door-to-balloon times were 90 min or more across arrival modes and accreditation status.The characteristics of patients and hospitals and the in-hospital delay were compared between walk-in and EMS-transported patients, with the use of the chi-square test for categorical variables and the p < 0.05 considered the level of statistical significance. Hospital was added as a random effect term in the models to adjust for unobserved hospital-level factors. All statistical analyses were performed using R software.To account for clustering of patients within hospitals, we employed generalized linear mixed models with a random effect term for the hospital to examine the associations of arrival mode and accreditation status with in-hospital delay (Model 1). The logistic regression was performed for the percentage of cases with door-to-balloon time of more than 90 min, and the effect estimates are reported as odds ratios (ORs) and 95% CI. For the door-to-balloon time, the effect estimates were calculated from the linear regression and reported as changes in minutes. Variables included in the models were selected based on their physiological relevance and potential to be associated with outcomes. We initiated the model development with a crude model (no adjustment) and then added a range of covariates into the regression models based on previous studies in the literature ,17,18,19p < 0.001), lower systolic blood pressure , lower diastolic blood pressure , and lower rate of Killip I status . Regarding hospital-level characteristics, 72.2% of EMS-transported patients arrived at urban hospitals, slightly larger than the proportion of walk-in patients .A total of 4186 STEMI patients undergoing PCI from 33 hospitals were enrolled in this study, including 1284 (30.7%) EMS-transported patients and 2902 (69.3%) walk-in patients. The overall median age of the patients was 60 years, and 80.5% were men. The patients admitted to hospitals before, during, and after accreditation accounted for 43.2%, 13.7, and 43.1%, respectively. A comparison of patient- and hospital-level characteristics by arrival mode is presented in p < 0.001) and the percentage of cases with door-to-balloon time more than 90 min  in EMS-transported patients were lower than those in walk-in patients.The in-hospital delay also varied in the two groups of patients  and by dAfter adding the interaction term between accreditation status and arrival by EMS, the negative associations between ‘after accreditation’ status and in-hospital delay remained statistically significant and had larger coefficient sizes in the likelihood of door-to-balloon time being more than 90 min  and the door-to-balloon time . In terms of differences in arrival mode, the coefficient sizes of arrival by EMS were also larger in the in-hospital delay: the likelihood of door-to-balloon time being more than 90 min  and the door-to-balloon time .The OR of the interaction term of arrival by EMS and ‘during accreditation’ was statistically insignificant, suggesting that arrival by EMS did not modify the effect of accreditation process on in-hospital delay. The OR of the interaction term of arrival by EMS and ‘after accreditation’ was 1.59 , indicating that completed accreditation widened the disparity in the in-hospital delay between walk-in and EMS-transported patients. The impact of completed accreditation on the likelihood of door-to-balloon time being more than 90 min for EMS-transported patients was 59% greater than that for walk-in patients . SimilarTo the best of our knowledge, this was the first study to identify the modifying role of arrival mode in associations of chest pain center accreditation with in-hospital delay. Our results reflect an overall significant reduction in the in-hospital delay among STEMI patients after hospitals were accredited; however, the improvement was inconsistent between walk-in and EMS-transported patients. Our findings suggest that the healthcare quality improvement initiative may widen the disparity in treatment delay for patients with different arrival modes, providing implications for the optimization of implementation strategies for the continuous quality improvement of healthcare for acute chest pain.Our results showed that compared with ‘before accreditation’, both ‘during accreditation’ and ‘after accreditation’ statuses were associated with lower prevalence of in-hospital delay among STEMI patients undergoing primary PCI. This finding is generally consistent with studies conducted in other regions, which indicated that chest pain center accreditation was associated with improved processes and outcomes for patients with STEMI ,12,20. GThere are several potential explanations for the observed disparity in sensitivity to chest pain center accreditation efforts. First, establishment of a regional collaborative healthcare network from a multiagency approach was emphasized in the current practice for achieving chest pain center accreditation criteria. Delivery of EMS always occurs across multiple sectors, including emergency departments, centers for prehospital care, ambulance stations, and day care or primary healthcare centers, and it requires at least two different services, with each service provided by different settings. Care coordination is critical for the delivery of EMS to ensure that healthcare professionals interact with each other to provide timely and efficient healthcare. A large number of studies have also shown that the transmission of prehospital electrocardiogram and prehospital diagnosis is the primary basis for a hospital to decide whether to bypass the emergency department and cardiac care unit, which can reduce the in-hospital delay for EMS-transported STEMI patients ,22,23. PIn addition to the integration of prehospital and hospital care, implementation measurements required by the chest pain center accreditation criteria could also provide a plausible explanation for the mitigation of in-hospital delay among STEMI patients requiring primary PCI. Accredited hospitals continuously report data on individual patients for quality monitoring and assessment. The indicators for measuring clinical performance quarterly and annually are reported, and a ranking is calculated based on the percentile of each indicator and a weighted composite score. In terms of auditing and feedback regarding clinical performance, an improvement in adherence to the guideline recommendations is facilitated through monthly and quarterly hospital-specific performance feedback reports. The hospital-specific data are compared against a variety of internal and external benchmarks, including the temporal trend in performance and comparison points to regional or national performance thresholds, led by the National Health Commission of China. A series of regular meetings and case management and case study meetings are carried out at least once every quarter to share ‘best practice’ clinical support tools in hospitals. Regarding educational outreach to clinicians, routine educational programs are organized, and the contents of training include rules and guidelines for chest pain center construction, clinical skills for the diagnosis and treatment of STEMI cases, and standardization and guidelines for real-time data reporting. These dimensions of implementation measurements required by the chest pain center accreditation criteria could also benefit the development of public health capacity and capability to respond to public health emergencies by saving resources for triage, promoting efficiency of transfer, and optimizing timeliness of treatment.The current findings suggest that some attention should be channeled to walk-in patients in order to eliminate the inequality of the implementation effect of the healthcare quality improvement between patients with different arrival modes. The strategies to deal with this disparity might include, but are not restricted to, the following suggestions. From the patient level, health education on recognition of the onset symptoms of STEMI and awareness of seeking treatment by calling EMS should be encouraged and perhaps conducted by community healthcare centers and hospital-based chest pain centers. The existing evidence indicates that wider use of EMS by patients with acute chest pain may offer a considerable opportunity for improvement in public health ,22,25,26There were some limitations to this study. First, the nature of the cross-sectional design of this study restricted us to making causal inferences between the chest pain center accreditation and decreased in-hospital delay. Rather, the associations found in the present study underscore the need for research to capitalize on chest pain center accreditation to mitigate in-hospital delay. Second, this study included patients who were undergoing PCI; therefore, the results cannot be generalized to all patients with STEMI. Third, we were unable to adjust for medical history and socioeconomic indicators  due to the unavailability of relevant data for the patients. However, a previous publication suggested that these variables are not associated with in-hospital delay but might be associated with pre-hospital delay and mortality . MoreoveAmong STEMI patients undergoing primary PCI, EMS-transported patients were more sensitive to the shortened in-hospital delay associated with chest pain center accreditation efforts. This effect might exacerbate the existing disparity in in-hospital delay among patients with different arrival modes. Thus, more attention should be paid to walk-in patients and more strategies for increasing the utilization of EMS should be considered in further healthcare quality improvement.


Aim: Low back pain affects many people at some point in their life. Whenever pharmacologic and other conservative treatments of chronic pain fail, ablative and interventional methods are attempted on the assumption that interrupting nerve conduction prevents central pain cognition. Pulsed radiofrequency using multifunctional epidural electrodes can be used for multiple etiologies of chronic low back and leg pain with a low complication rate and minimal side effects.Methods: The records of the 188 patients who underwent pulsed radiofrequency with multifunctional epidural electrode between October 2014 and March 2017 in Algology clinic were examined retrospectively. Visual analogue scale (VAS) for pain, response to straight leg raising test (SLR), lumbar range of motion, analgesic use, patient satisfaction score, need for open operation or other interventional procedure were collected.Results: VAS and SLR tests were found to be significantly improved compared with the preoperative values. The VAS scores at the 10th day and first, third and sixth months were significantly decreased compared to baseline scores (p<0.001). Also, SLR tests were significantly improved compared to baseline scores at the same intervals (p<0.001).Conclusion: Pulsed radiofrequency with multifunctional epidural electrode is a safe and effective method for low back pain which is caused by several pathologies. Low back pain is a condition that affects many people in a certain period of their lives. Most of the patients (> 85%) applying to primary care due to low back pain have non-specific low back pain, in other words, the underlying cause of their low back pain cannot be defined precisely ,2.Low back pain has the highest prevalence in people aged from 40 to 80 years and it has been observed that the prevalence of chronic low back pain has changed over the years due to the change in lifestyles and technology. Two studies have shown that the prevalence of chronic low back pain has doubled over time ,4. This The cause of low back pain is mostly non-specific . The leaPrimary care for the treatment of low back pain includes non-invasive treatment and non-drug methods, such as patient education and suggestions on active life and exercise . NeverthApplying epidural or transforaminal corticosteroid injections and dorsal root ganglion (DRG) radiofrequency ablation are invasive treatment options in cases where conservative treatments are insufficient . The fleFollowing the Ethics Committee of Uludag University Faculty of Medicine approval (2017-17/45), the study was performed as the retrospective analysis of the medical files of patients admitted to the Clinics of the Algology Department and underwent pulsed radiofrequency (PRF) with multifunctional epidural electrode between October 2014 and March 2017. Patients who had low back pain with unilateral/bilateral radicular pain due to various aetiologies, who had no improvement of pain despite medical treatment and other standard treatment methods, and who were regarded as Class I-III according to the American Society of Anaesthesiologists (ASA) classification were included in the study. We investigated post-procedure Visual Analogue Scale (VAS) scores, response to straight leg raise (SLR) test, range of motion (ROM) of the lumbar joints, use of analgesics, and patient satisfaction level, and whether the patient had any operation or invasive procedure after PRF with multifunctional epidural electrode.Data of 188 patients meeting the inclusion criteria were examined. Thirty-six patients who did not show up for the post-procedure follow-up visit or whose data could not be accessed were excluded from the study. As a result, the data of 152 patients were evaluated within the scope of the study.Age, gender, BMI, ASA class, comorbidities and pain duration were recorded for each patient. If they had a history of surgery or neuropathic complaints were also recorded. The patients’ VAS scores before the procedure and after the procedure and at the post-procedural 10th day and first, third and sixth months, response to straight leg raise test before and after the procedure, analgesic use before and after the procedure, and the range of motion values measured before and after the procedure were recorded. After the procedure, patient satisfaction was recorded on a 0-4 scale . In our study, the range of motion was measured with a goniometer, and the straight leg raise test was performed as described above and the results were recorded in angles.Normal distribution of variables was assessed using the Shapiro-Wilk test. Continuous variables are expressed with the median (minimum-maximum) and average±standard deviation values. Categorical variables are expressed as % (n=). The dependent paired samples Wilcoxon test was used for comparisons between the groups generated according to the results of the normal distribution tests. Statistical Package for Social Sciences (SPSS) version 21  was used for statistical analyses. p<0.05 was considered statistically significant.Pulsed radiofrequency application with multifunctional epidural electrode (PASHA electrode)After establishing peripheral vascular access, we apply electrocardiography (ECG), pulse-oximetry (SpO2) and non-invasive blood pressure monitoring for patients in accordance with the recommendations of ASA. Patients are placed in the prone position and a neutral electrode is located on the appropriate site. The intervention site is sterilized with antiseptic solution and covered. Sterile conditions are maintained during the procedure. Sacral hiatus is identified, and 3 ml of 2% prilocaine solution is applied to the subcutaneous and deep tissues as the local anaesthetic. Epidural space is accessed using a 14-gauge introducer cannula. Radiopaque material is injected through the cannula and its location is confirmed with fluoroscopy. The multifunctional electrode is advanced through the cannula and placed at the targeted spinal level, dorsal column of medulla spinals or cauda equina nerves, according to MRI, in the craniolateral direction. Its location is checked with anteroposterior, oblique and lateral fluoroscopic images. The proximal end of the catheter is attached to the radiofrequency generator in a sterile way. After observing proper placement, stimulation is applied at 0.8 V, 50 HZ sensory stim, and the location of the catheter is confirmed when patients feel a stimulation in their symptom area; the point of application is determined. PRF is applied at 42 °C for 240-360 seconds with an active phase of 20 milliseconds and a silent period of 480 milliseconds. After the application, the catheter is withdrawn. Patients are followed up for four to six hours for a loss in motor function, sensation and other complications. On the follow-up visit, patients’ VAS scores, SLR test results, joint range of motion, and satisfaction levels are recorded.Demographic data and distribution of ASA scores of 152 patients are shown in Table Most common diagnoses in patients receiving pulsed radiofrequency with multifunctional epidural electrode were respectively lumbar disc herniation (LDH) , spinal stenosis , and spondylolisthesis plus spinal stenosis .The median VAS score of 152 patients examined in the study before treatment was 6 (4:10) (average±standard deviation: 6.59±0.99). The VAS scores evaluated on day 10 and months one, three, and six after treatment were significantly lower as compared to the VAS values obtained before treatment  Table . In the study, the Wilcoxon test was used to compare the pre-treatment VAS values with the VAS values measured 10 days and one, three, and six months after treatment Table . The preWe compared the pre-treatment straight leg raise test values with the post-treatment straight leg raise test values according to diagnosis. In the patients with LDH, the post-treatment SLR values were found to be significantly higher than the pre-treatment SLR values (p<0.001). In the patients with spinal stenosis, the post-treatment SLR values were also significantly higher compared to the pre-treatment SLR values (p<0.001). furthermore, the post-treatment SLR values of patients with spondylolisthesis plus spinal stenosis were also found to be significantly higher compared to the pre-treatment SLR values (p=0.083).We compared the pre-treatment range of motion for joint flexion with the post-treatment range of motion by diagnosis. In the group diagnosed with LDH, the post-treatment flexion ROM was found to be significantly increased compared to pre-treatment (p=0.003). In the group of patients with spinal stenosis, no significant difference was found between pre-treatment and post-treatment ROM values in flexion (p=0.102). Similarly, there was no significant difference between pre-treatment and post-treatment ROM values for flexion in patients with spondylolisthesis plus spinal stenosis (p=0.157).We compared the pre-treatment range of motion for joint extension with the post-treatment range of motion by diagnosis. In the patients with LDH, the post-treatment ROM values for extension were found to be significantly higher as compared to the pre-treatment ROM values (p<0.001). On the other hand, no significant difference was found between pre-treatment and post-treatment extension ROM values in the group diagnosed with spinal stenosis (p=0.066). There was no significant difference between pre-treatment and post-treatment ROM values for flexion in the group with spondylolisthesis plus spinal stenosis (p=0.059).We made a comparison between the pre-treatment range of motion for lateral flexion and the post-treatment range of motion for lateral flexion according to patients’ diagnoses. In the group diagnosed with LDH, the post-treatment ROM values for lateral flexion were found to be significantly higher than the pre-treatment ROM values (p<0.002). Nevertheless, there was no significant difference between pre-treatment and post-treatment lateral flexion ROM values in the group diagnosed with spinal stenosis (p=0.046). There was no significant difference between pre-treatment and post-treatment ROM values for lateral flexion in the group with spondylolisthesis plus spinal stenosis (p=0.157).Whereas 113 patients (74.3%) were using analgesic before treatment, this was decreased to 83 patients (54.6%) after the procedure. It was observed that the number of patients undergoing a physiotherapy protocol was 58 (38.2%) before treatment and it decreased to 11 (7.2%) after treatment. The number of patients who received interventional treatment by algology physicians before the application of pulsed radiofrequency with multifunctional epidural electrode was 65 (42%), and 87 (57%) did not have any history of surgery.There were 42 patients 27.6%) with a history of surgery before treatment, whereas 24 patients (15.8%) underwent surgery after treatment. When the patients who had history of surgery before the treatment were examined, it was observed that the VAS scores prior to the application of the pulsed radiofrequency with multifunctional epidural electrode were significantly higher than the VAS scores recorded on the 10th day and in the 1st, 3rd and 6 months after the treatment . Moreover, when the patients who did not have history of surgery before the treatment were examined, the VAS scores prior to the application of the pulsed radiofrequency with multifunctional epidural electrode were also significantly higher than the VAS scores recorded on the 10th day and in the first, third and sixth months after the treatment  . Similarly, the post-treatment SLR values of the group without a history of surgery were significantly higher than the pre-treatment SLR values (p<0.001).Furthermore, the pre-treatment range of motion for flexion was compared with the post-treatment range of motion in patients with and without a surgical history prior to the application of pulsed radiofrequency with multifunctional epidural electrode. In the group with a history of surgery, the post-treatment ROM values for flexion were significantly higher compared to the pre-treatment values (p<0.034). In the group without a history of surgery, the post-treatment ROM values for flexion were significantly higher compared to the pre-treatment values (p=0.003).We also compared the pre-treatment range of motion for extension with the post-treatment range of motion in patients with and without a surgical history before the application of pulsed radiofrequency with multifunctional epidural electrode. There was no significant difference between pre-treatment and post-treatment extension ROM values in the group that had surgery prior to the treatment (p=0.066). On the other hand, the post-treatment ROM values for extension were significantly higher compared to the pre-treatment values in the group without a history of surgery (p<0.001).A comparison was also made between the pre-treatment and post-treatment range of motion levels for lateral flexion in patients with and without a surgical history prior to the application of pulsed radiofrequency with multifunctional epidural electrode. No significant difference was determined between the pre-treatment and post-treatment ROM values for lateral flexion in the group that had surgery prior to the treatment (p=0.083). In the group without a history of surgery, the post-treatment ROM values for lateral flexion were significantly increased compared to the pre-treatment values (p<0.001) Table .The number of patients that had neuropathic pain complaints before treatment was 58 (38.2%), and the number of patients whose pain had no neuropathic feature was 94 (61.8%). When the patients who had neuropathic pain were analysed, it was observed that their VAS scores prior to the application of the pulsed radiofrequency with multifunctional epidural electrode were significantly higher than the VAS scores measured 10 days and one, three and six months after the treatment . Moreover, patients who had low back pain without radicular leg pain were examined; the VAS scores prior to the application of the pulsed radiofrequency with multifunctional epidural electrode were significantly higher compared to the VAS scores on the 10th day and in the first, third and sixth months after the treatment .There were no complications in the 152 patients whose data we examined. None of the 152 patients developed neurological dysfunction after the procedure.Patient satisfaction score was 1 in 21 (13.8%), 2 in 26 (17.1%), 3 in 39 (25.7%), and 4 in 66 (43.4%) patients at six months after the procedure. There were no patients with a satisfaction score of zero.The mechanism of action of PRF in pain management is currently not clarified with certainty. According to general opinion, radiofrequency has neuromodulatory and anti-inflammatory effects. Microscopic damage is evaluated after exposure to radio waves, as observed in membrane abnormalities and mitochondrial morphology, as well as in interruption and disorganization of microfilaments and microtubules. This ultrastructural pathway occurs more widely in type C and type A nerve fibers. Immune cells are affected by radio waves and inhibit the production of pro-inflammatory cytokines, such as interleukin-1b and interleukin-6 (IL-6). Radiofrequency can induce changes in membranes and intracellular structures, consequently modifying the transmission of action potentials and perception of pain. PRF activates the descending noradrenergic and serotoninergic pain inhibition pathways as well as inhibits excitatory nociceptive C fibers. Microglial activity can be decreased by PRF intervention in DRG. Microglia can cause chronic neuropathic pain through the release of various cytokines and chemokines associated with the transmission of pain signals and also decreased microglial activity may prevent the development of chronic neuropathic pain . On the The patients included in the study were with or without history of surgery whose pain was not relieved with more conservative methods. Some of the patients had indications for surgery, but did not want to undergo surgery or had a high risk for surgery due to their medical condition. The VAS scores of the patients who underwent pulsed radiofrequency with multifunctional epidural electrode were significantly lower 10 days and one, three and six months after the procedure as compared to the pre-treatment values.The prevalence of chronic low back pain by age varies between studies, but it is three to four times more prevalent in the group over 50 years of age than in the group aged 18-30 years . SimilarIn our study, PRF application with multifunctional epidural electrode was most frequently applied to patients with diagnoses of lumbar disc herniation (n=92), spinal stenosis (n=47), and those with spondylolisthesis and spinal stenosis (n=13), respectively. Disc herniation is the most frequent cause of lumbar radicular syndrome in patients under 50 years. After the age of 50, radicular pain often occurs due to degenerative changes in the spine .Pulsed radiofrequency applied to the dorsal root ganglion (PRF-DRG) is an attractive alternative to epidural steroid injection in the treatment of chronic lumbar radicular pain. In pulsed radiofrequency, it is possible to perform target-specific applications and avoid the use of steroids, and thus, eliminate endocrine effects including adrenal suppression, water retention and glucose intolerance. It is known that the injection of steroids, and also of steroid particles, into the artery have potentially serious adverse effects including spinal cord infarction and death . There aMost of the studies investigating the effects of PRF have been conducted with the transforaminal approach. The multifunctional flexible electrode has advantages over rigid equipment, such as the ability to apply stimulation more closely to the DRG and to infuse drugs into the epidural space . Thanks It was observed when the patients were grouped by diagnosis that the VAS scores of the patients diagnosed with LDH were significantly lower 10 days and one, three and six months after the procedure compared to prior to the procedure. There are many studies indicating that the application of PRF to DRG is a safe procedure. Choi et al. reported that 71% of patients with chronic cervical radicular type pain resistant to repeat transforaminal epidural steroid injections (TFESIs) were satisfied with the effectiveness of PRF-DRG ,21. A prospective randomized trial conducted on patients with radicular pain due to a herniated disc made a comparison between PRF and transforaminal steroid injection, and the VAS scores for cervical and lumbar radicular pain were found to be significantly decreased at the 12th week following the treatments in both groups. There was no statistically significant difference between the PRF and TFESI groups in the VAS, Oswestry Disability Index (ODI) and Neck Disability Index (NDI) scores in any period of the follow-up. Applying PRF to dorsal root ganglion is as effective as TFESI in radicular pain caused by disc herniation, and it allows avoidance from the side effects of the steroids . Based oLumbosacral radicular pain is characterized by a radiating pain in one or more lumbar or sacral dermatomes, and it may or may not be accompanied by symptoms of function loss and other radicular irritation symptoms .A retrospective study investigated patients with radicular syndrome due to disc herniation, spinal stenosis and failed back surgery syndrome (FBSS) that underwent PRF, and reported a significant decrease in analgesic consumption in the groups with disc herniation and spinal stenosis. However, no significant decrease was reported in the analgesic consumption of patients with failed back surgery syndrome . Van BoxShanthanna et al. introduced the first randomized controlled study on the effects of PRF in the treatment of chronic radicular pain . The autIn the prospective randomized trial conducted by Ross et al. on 197 patients, who once underwent lumbar surgery, the epidural scarring caused by lumbar surgery was followed up with magnetic resonance imaging. It was observed in the comparison between epidural scarring and radicular pain that patients who had extensive epidural scarring were 3.2 times more likely to experience recurrent radicular pain . It was In this study, the pre-procedural analgesic use was 74.3% in all groups, but this rate decreased to 54.6% after the procedure. Cohen et al. showed that the application of PRF to the peripheral nerve is superior to conservative medical treatment in patients with thoracic segmental pain .In studies of PRF application with multifunctional epidural electrode, no major or minor complications have been reported, except for headache lasting for a maximum of one day after treatment . MoreoveThe greatest problem in the studies investigating PRF is that there is no standardization in PRF parameters, and the inclusion criteria and reports are heterogeneous . In two The major weakness of our study is that it is a retrospective study and does not include a control group. However, it provides valuable information on the efficacy and potential complications of the multifunctional epidural electrode, on which there is limited data in the literature.In conclusion, it has been demonstrated that pulsed radiofrequency procedure with multifunctional epidural electrode is an effective and safe method in the short- and medium-term for lumbar spinal pain reflected on the low back and legs.Low back pain is a condition that affects many people in a certain period of their lives. It has been observed that the prevalence of chronic low back pain has changed over the years due to the change in lifestyles and technology. Primary care for the treatment of low back pain includes non-invasive treatment and non-drug methods, such as patient education and suggestions on active life and exercise. Patients that have low back pain accompanied with severe and progressive loss of motor strength or signs of cauda equine should be immediately referred to surgery. Applying epidural or transforaminal corticosteroid injections and dorsal root ganglion (DRG) radiofrequency have become common next steps in care where conservative treatments are insufficient. In this study, patients, who had low back pain due to various aetiologies, who had no improvement of pain despite medical treatment and other standard treatment methods, were included in the study and it has been demonstrated that pulsed radiofrequency procedure with multifunctional epidural electrode is an effective and safe method in the short- and medium-term for lumbar spinal pain reflected on the low back and legs.


Pain management in burn patients is a complex ongoing problem. Opioid and non-opioid medications have historically been used as the primary pain management modality in burn care. Considering the ongoing opioid epidemic, a multidisciplinary holistic approach is needed for pain management. Acupuncture has been recognized to help in different settings such as chronic back pain, neurological problems, depression, and anxiety.We hypothesize that burn and wound patients receiving acupuncture will have a decrease in opioids and non-opioid medications on acupuncture day (ACd) compared to non-acupuncture day (n-ACd) and a reduction of pain scores before and after acupuncture.A prospective observational study in all patients admitted to the burn service was made. We exclude patients that were unable to provide consent or age 6 years and younger.A numeric pain score (1-10) was collected from the patients before and after each acupuncture session; if patients were sleeping after acupuncture pain score was collected when they woke up. A prospective collection of daily opioids and non-opioids medications was made. Opioids were converted to daily morphine equivalents (MME).From February to August 2021, 53 patients on the burn service were treated with acupuncture for a total of 185 sessions. The median age was 49 years (IQR:32.5-63.0). Median TBSA for burn patients was 3.3% (IQR:1.5-8.1). The number of sessions per patient ranged from 1-12 with a median of 3 (IQR1.7-4). Before acupuncture, the median pain score was 5 (IQR:2.6-6.4), and after treatment was it was 1.5 (IQR:0.2-2.8).Of 185 sessions, 49 (26%) of those sessions, patients fell asleep afterward. Median morphine use on ACd was 26.6 MME (15.8-62.1) vs. n-ACd 27.35 MME (15.5-65.3). For non-opioid medication, the median of acetaminophen on ACd 1007.5mg (313.39 -1950) vs. n-ACd 1381.25mg (642.5-2535).After adjusting for TBSA and chronic opioid use, patients were given a daily mean of 391 MME CI: (1201.12-419.12 p=0.334) less in ACd vs. n-ACd. In addition, acetaminophen had a daily mean of 395.12mg CI:  less in ACd vs. n-ACd.Overall, acupuncture was associated with a significant lower pain score with a mean of 2.799 points less.Acupuncture seems to abrogate pain in burn and wound patients, as demonstrated by doses of pain medication. While there was no significant difference in opioid medications, there was a significant difference in acetaminophen, indicating that additional education of a tiered approach to pain medications is essential to reduce unnecessary opioid use.