In the United States, emergency medical services (EMS) protocols vary widely across jurisdictions. We sought to develop evidence-based recommendations for the prehospital evaluation and treatment of chest pain of suspected cardiac origin and to compare these recommendations against the current protocols used by the 33 EMS agencies in the state of California.We performed a literature review of the current evidence in the prehospital treatment of chest pain and augmented this review with guidelines from various national and international societies to create our evidence-based recommendations. We then compared the chest pain protocols of each of the 33 EMS agencies for consistency with these recommendations. The specific protocol components that we analyzed were use of supplemental oxygen, aspirin, nitrates, opiates, 12-lead electrocardiogram (ECG), ST segment elevation myocardial infarction (STEMI) regionalization systems, prehospital fibrinolysis and β-blockers.The protocols varied widely in terms of medication and dosing choices, as well as listed contraindications to treatments. Every agency uses oxygen with 54% recommending titrated dosing. All agencies use aspirin , as well as nitroglycerin and opiates (58% choosing morphine). Prehospital 12-Lead ECGs are used in 97% of agencies, and all but one agency has some form of regionalized care for their STEMI patients. No agency is currently employing prehospital fibrinolysis or β-blocker use.Protocols for chest pain of suspected cardiac origin vary widely across California. The evidence-based recommendations that we present for the prehospital diagnosis and treatment of this condition may be useful for EMS medical directors tasked with creating and revising these protocols. The care provided by emergency medical services (EMS) varies widely in the United States. The Institute of Medicine report, “EMS at the Crossroads,” notes that an area of improvement for EMS is the need for more uniform quality care and the need to develop measures for EMS quality. The EMS Medical Directors Association of California (EMDAC) is a professional organization whose members include the directors of these agencies along with other interested EMS medical directors. The function of EMDAC is to provide support and guidance to the various agencies as well as to make recommendations to the California EMS Authority about policy, legislation and scope of practice issues. In an effort to improve the quality of EMS care in our state, EMDAC has endeavored to create evidence-based recommendations for EMS protocols. These recommendations are intended to assist medical directors of the various LEMSAs in developing protocols that are of high quality and evidence based. We hope to provide a summary of the evidence for the prehospital treatment of chest pain of suspected cardiac origin and to measure the consistency of current California protocols.A subcommittee of EMDAC endeavored to create a narrative review of the existing evidence for prehospital treatment of chest pain. The subcommittee chose by consensus the elements that should be included in any protocol for chest pain of suspected cardiac origin.Clinical questions regarding these interventions were developed in the population, intervention, control group and outcome format. Our population was those patients in the prehospital setting with chest pain of suspected cardiac origin. The intervention varied by clinical question. The control group consisted of patients who were not receiving the specific intervention, and outcomes were defined by resolution of electrocardiographic (12-lead ECG) findings, chest pain resolution, infarct size and mortality. The outcomes varied considerably depending on the individual study design. These commonly included cardiac events, rate of myocardial infarction (MI), arrhythmias, shock, death, length of stay, infarct size, need for percutaneous intervention (PCI) and/or ejection fraction.We relied heavily on recommendations made by various organizations that have performed systematic reviews and meta-analyses regarding these treatment interventions including the American Heart Association (AHA), the Cochrane Group and the International Liaison Committee on Resuscitation (ILCOR). We supplemented the recommendations from these organizations with additional literature searches through PubMed for each specific question.The process used for assigning levels of evidence (LOE) and grading our recommendations was taken from the American College of Emergency Physicians (ACEP) process of creating their clinical policies with slight modification to better fit our objectives. A committee of EMDAC reviewed studies and assigned LOE based on the study design, including features such as data collection methods, randomization, blinding, outcome measures and generalizability. Prehospital recommendations with a strong degree of certainty based on one or more LOE I studies or multiple LOE II studies.Prehospital recommendations with a moderate degree of certainty based on one or more LOE II studies or multiple LOE III studies.Prehospital recommendations that are based on only poor quality or minimal LOE III studies or based on consensus.No recommendation will be given in those cases where only preliminary data or no published evidence exists and we have no expert consensus. We may also withhold recommendation when studies, no matter their LOE, currently show conflicting data.After answering the clinical question and providing recommendations for diagnostic and treatment interventions, each current chest pain protocol for the 33 agencies were reviewed for consistency with the recommendations. The clinical protocols were reviewed during the month of July 2015. Institutional review board approval was deemed to not be necessary for this review of publicly available research and clinical protocols.Does the prehospital administration of oxygen to patients with chest pain and normal oxygen saturations improve outcomes in cases of suspected acute coronary syndrome (ACS)?There have been few randomized controlled studies that have attempted to answer this question. A study in 1976 by Rawles et al. randomized patients to oxygen or air and found more deaths in the oxygen group, although not clinically significant. 8There is no evidence that the routine use of oxygen to patients with normal oxygen saturations provides any benefit, but may cause harm.We recommend against routine oxygen supplementation in normoxic patients (oxygen saturation of 94% or greater) with suspected ACS. 9None given.Oxygen saturations should be titrated between 94%-98% (consensus).Does the prehospital administration of aspirin to patients with suspected ACS improve outcomes with an acceptable rate of adverse events?There is high-quality evidence demonstrating benefit of aspirin administration 162.5mg) in improving mortality among patients with an acute myocardial infarction (MI). mg in imp13We recommend the administration of aspirin to adults with chest pain due to suspected ACS. In making this recommendation, we place a higher value on the benefits of aspirin , which outweigh the risks of adverse effects . Aspirin is contraindicated in the setting of known aspirin allergy.None given.None given.Does the administration of nitroglycerin in the prehospital setting to patients with suspected ACS improve outcomes when compared to not using nitrates?There have been no trials to specifically evaluate the usefulness of nitrates in the field or in the emergency department (ED) among patients with chest pain of suspected ACS. None given.None given.If nitroglycerin is used, then the following contraindications should be part of the protocol (expert consensus):Contraindications with hypotension, defined as a systolic blood pressure less than 90mmHg, by expert consensus.Contraindications with suspected right side/inferior infarct.Contraindication with the recent use of phosphodiesterase-5 inhibitors for erectile dysfunction or pulmonary hypertension.Although it is reasonable to consider the early administration of nitroglycerin in selected patients without contraindications, insufficient evidence exists to support or refute the routine administration of nitroglycerin in the ED or prehospital setting in patients with suspected ACS. 5Does the administration of opiates to patients with suspected ACS improve outcomes when compared to not using opiates?Clear benefit to opiate administration is unclear. There is a single study that suggested mortality and rates of infarction are more prevalent in patients who receive morphine with Non STEMI. None given.None given.If opiates are used, they should be administered intravenously and titrated to pain relief (consensus). Contraindications with hypotension, defined as a systolic blood pressure less than 90mmHg.Although it is reasonable to consider the early administration of opiates in selected patients without contraindications, insufficient evidence exists to support or refute its routine administration in the ED or prehospital setting in patients with chest pain of suspected ACS. There is only one poor quality study that demonstrated harm.Does the prehospital use of a 12-lead ECG increase the diagnostic sensitivity and specificity of STEMI among patients with chest pain of suspected ACS when compared to not using a prehospital 12-lead ECG? 5Several studies have demonstrated that prehospital 12-lead ECGs can improve the recognition of STEMI with reasonable sensitivity and specificity. 30In patients with suspected ACS, a 12-lead ECG should be acquired and interpreted by prehospital or emergency providers as soon as possible after first patient contact. The interpretation should be used in conjunction with the clinical signs and presentation for diagnosis and triage, including destination decisions.Repeated prehospital 12-lead ECGs may improve diagnostic accuracy of STEMI. Transmitted 12-lead ECGs may be useful in decreasing door-to-intervention times. The timely notification of the STEMI-receiving center is helpful in decreasing door-to-intervention times. Prehospital activation of the catheterization lab may also help to decrease door-to-intervention times. Computer interpretation of 12-lead ECGs may help to increase the specificity of the diagnosis, especially with less experienced paramedics.None given.Does the regionalization of STEMI care lead to decreased door-to-intervention times and improved patient outcomes in prehospital patients with STEMI when compared to a non-regionalized program?It has been shown in multiple studies that primary PCI is the ideal method of reperfusion in patients presenting with STEMI. Rapid inter-facility transfers of patients with STEMI presenting to a non-PCI hospital can reduce time to treatment. STEMI systems should include an organized inter-facility transfer process that includes inter-hospital agreements and ambulance dispatch protocols designed to minimize transfer time.There is a large body of evidence suggesting that primary PCI is superior to thrombolytics. There is also evidence suggesting benefit of STEMI regionalization programs in decreasing door-to-intervention times. We recommend EMS systems employ a regionalization program for STEMI patients that provide direct transport to PCI capable centers. In cases where timely transport to a PCI center is not possible (>90min), transport to a facility that can provide thrombolytic therapy is reasonable.None given.None given.In patients with STEMI and a prolonged time to primary PCI, does the use of prehospital fibrinolytics improve outcomes?There is a significant body of high-quality evidence describing the benefit of fibrinolytic therapy given to patients with STEMI when it is anticipated that primary PCI cannot be performed within 120 minutes of first medical contact. None given.None given.For those patients with a STEMI, onset of ischemic symptoms within the previous 12 hours and primary PCI cannot be accomplished within 120 minutes of first medical contact, prehospital fibrinolytics can be considered. There should be considerable oversight for any prehospital thrombolytic program. Because it is not in the current scope of practice for paramedics in California, this could only be done as a pilot study with approval from the EMS Authority.Does the prehospital administration of a β-blocker to patients with an acute STEMI improve outcomes?Current recommendations by the AHA are that a β-blocker be administered in the first 24 hours after an acute MI. 42None given.None given.None given.While the prehospital administration of β-blockers does seem to show promise, there are insufficient studies at this time to make a prehospital treatment recommendation regarding their use in the field.All 33 agencies protocols were identified and reviewed for consistency with the recommendations made by EMDAC for chest pain of suspected cardiac origin. Every agency has a protocol relating to the treatment of chest pain, though these protocols vary significantly in content and organization. Examples of suggested language for protocol development that the committee felt was most consistent with the recommendations were taken from the agency protocols.Every agency has a component of oxygen administration in their protocol for chest pain. Routine use of oxygen, regardless of the patient’s oxygen saturation is recommended in 39% of agencies, with 54% percent of agencies advising a titrated dose to their providers . Only foThe use of aspirin for chest pain of suspected cardiac etiology is universal among our agencies . There iThere is also great variability in what are considered contraindications to aspirin use. Aspirin allergy is specifically noted as a contraindication in 58% of agencies and recent gastrointestinal bleeding is noted in 30% of agencies. Two agencies noted peptic ulcer disease as a contraindication and one noted asthma, chest pain radiating to the mid back and chronic anticoagulant use as contraindications. Some protocols clarify that aspirin is indicated in the setting of the use of other anticoagulants (e.g. warfarin) or of gastrointestinal disease without a recent bleeding episode.All agencies include sublingual nitroglycerin, either tablets or spray, in the treatment of chest pain . One ageOpiate use for chest pain is recommended in all protocols. Morphine sulfate is the opiate used in 58% of agencies, while fentanyl is the opiate of choice in 15% of agencies . Both mePrehospital 12-lead ECGs are used in all but one of the 33 agency (97%) . TransmiAll but one (97%) of the agencies has some form of regionalization of STEMI care. These systems are not uniform in design and the capabilities of the systems vary widely based on geography and access to PCI capable receiving centers.There are currently no agencies that employ fibrinolytics in the field. One agency received approval in the past for a trial study of prehospital fibrinolytics for STEMI patients but enrolled no patients during the trial study period.The chest pain protocols reviewed varied greatly in content and structure between LEMSAs in California. These government agencies consist of either a county or region that develops a system of care that include first responders, ambulance transporters, and specialty receiving facilities. These systems reflect the needs and demographics of that county or region and operate under one set of medical control policies.A similar variation among protocols was seen in a recent study on state wide EMS protocols. 44Many agencies use some sort of titration language for oxygen use but only four restricted use with normal saturations. The current evidence seems to point towards more restrictive language for our protocols. Aspirin use, while universal, varied considerably in dosing and many agencies did not have contraindications clearly noted in their protocols. Local training could address these issues, even if not explicitly stated in the protocols themselves. Recent studies have demonstrated low rates of prehospital aspirin administration despite being almost universal in our protocols. 45Nitroglycerin is used by every agency with a wide variability noted in delivery route. Few agencies noted a contraindication with right-sided infarcts, with one agency not allowing nitrates in any patient with STEMI to avoid this potential contraindication. Most agencies did caution use with PDE5 Inhibitors. Holding nitroglycerin for hypotension was universal, but the systolic blood pressure cut-off varied. Our recommended cut-off is a systolic blood pressure of 90mmHg.Opiates were also found to be used in all protocols with many agencies preferring fentanyl over morphine. It should be noted that studies with fentanyl for ischemic chest pain are not available to specifically recommend this agent for suspected ACS.Twelve-lead ECGs were used in all but one agency. The technique used to interpret STEMI varied between agencies with some using computer interpretation, medic interpretation or both. Most agencies notified receiving centers of their potential STEMI and many have transmission capabilities.Prehospital fibrinolytics, while not employed at any agency, may still have a place for some rural systems without timely access to regionalized STEMI centers. Currently, paramedics in California do not have this in their scope of practice. If such a system were to be put in place it would require a trial study and substantial medical oversight.While many states have mandatory protocols in place for their providers, California has allowed the individual agencies to develop and implement their own protocols. While this has allowed for flexibility among regions with different populations and financial and geographic restrictions, it may also contribute to health outcome disparities among the agencies. A study by Kupas et al. coined the term “model” protocols, which were found to be present in 17 states. Protocols for chest pain of suspected cardiac origin vary widely across the state of California. The evidence-based recommendations that we present for the prehospital diagnosis and treatment of this condition may be useful for EMS medical directors tasked with creating and revising these protocols.


Multimodal analgesia is achieved by combining different analgesics and different methods of analgesic administration, synergistically providing superior pain relief when compared with conventional analgesia. Multimodal analgesia can also result in reductions in the side effects and complications of analgesia, thereby improving patient safety. Preventive analgesia, treatment before initiation of the surgical procedure, has a potential to be more effective in reducing pain sensitization than treatment initiated after surgery. Multimodal analgesia that includes prophylactic administration of selective cyclooxygenase-2 (COX-2) inhibitors can improve postoperative pain and reduce opioid analgesic consumption after total knee arthroplasty (TKA). However COX-2 inhibitors are not approved for use as preventive analgesia in Japan. Thus, assessing the effectiveness of COX-2 inhibitors during the early postoperative period is important to establish clinical practice guidelines in Japan. This study was designed to examine the effects of celecoxib administration immediately after surgery, in addition to multimodal analgesia, on postoperative pain management after TKA.This randomized, prospective, open-label controlled study will include 120 patients undergoing unilateral TKA. All patients will routinely receive single injections of femoral and sciatic nerve blocks, along with postoperative patient-controlled analgesia (PCA) with fentanyl. Patients will be randomly assigned to receive or not receive immediate postoperative administration of celecoxib. The primary outcome is a visual analog scale (VAS) pain score the second day after surgery. Secondary outcomes include opioid consumption, VAS pain score for 7 days after surgery, range of knee motion, evaluation of sleep quality, overall evaluations by patients and physicians, rates of postoperative nausea and vomiting, and consumption of rescue analgesics.The objective of this study is to evaluate the effects of celecoxib administration immediately after surgery on pain after TKA surgery. A randomized controlled trial design will address the hypothesis that administration of oral celecoxib immediately after surgery, along with multimodal analgesia that includes peripheral nerve block and PCA, could reduce VAS pain score after TKA surgery.UMIN-CTR 000014624 (23 July 2014) Surgical procedure could cause noxious stimulation. Many methods have been used to manage pain after surgery, including various drugs, routes of drug administration and medication methods. Recently, patient-controlled analgesia (PCA) has been more widely used because of its therapeutic effects and safety . PCA is Multimodal analgesia is achieved by combining different analgesics and different methods of administration, to provide superior pain relief synergistically compared with conventional analgesia . MoreoveSurgical noxious stimuli sensitize the nervous system to subsequent stimuli that could amplify pain. Preventive blocking of nociceptive stimuli to the central nervous system is beneficial in attenuating postoperative pain and in reducing the severity of postoperative pain . PreventTraditional NSAIDs inhibit both COX-1 and COX-2 isoenzymes. Celecoxib is a selective COX-2 inhibitor shown to be as effective as traditional NSAIDs as an analgesic for acute postoperative pain. Celecoxib has fewer gastrointestinal side effects than traditional NSAIDs, such as loxoprofen, diclofenac and ibuprofen –6. MoreoStudies have suggested that the administration of selective COX-2 inhibitors for preemptive, multimodal analgesia can improve postoperative pain and reduce the consumption of opioid analgesics after total knee arthroplasty (TKA) , 9. In JThis study was designed to assess the effects of celecoxib administration during the early postoperative period, along with multimodal analgesia, on postoperative pain management after TKA. We hypothesized that the administration of celecoxib immediately after TKA surgery would provide superior postoperative analgesia compared with delayed administration. Our aim is to compare patient-reported visual analog scale (VAS) pain scores, opioid consumption, range of knee motion, sleep quality, rates of postoperative nausea and vomiting, and rescue analgesic consumption in patients who do and do not receive COX-2 inhibitors, as well as to compare overall evaluations by patients and physicians.http://www.consort-statement.org/). The trial is registered under the University hospital Medical Information Network and clinical trial registry  000014624 (23 July 2014). An overview of the trial design is shown in Figs. This study is a single-center, randomized, prospective, open-label controlled trial, performed in accordance with the Declaration of Helsinki and approved by the ethics committee of the Tsukuba University Hospital Mito Clinical Education and Training Center, Mito Kyodo General Hospital, University of Tsukuba. Written informed consent will be obtained from each patient prior to enrollment and testing. This study follows the CONSORT statement .Patients with a history of complications or hypersensitivity to celecoxib, fentanyl or sulfonamides; a serious allergic reaction to any other drugs; aspirin-induced asthma; or gastrointestinal hemorrhage or ulcer will be excluded. In addition, patients will be excluded if they have severe hepatic, renal, or cardiovascular dysfunction; are in a perioperative period of coronary artery bypass surgery; are pregnant, lactating or probably pregnant. Patients with a history of drug abuse will be excluded. In this study, sleep quality will be evaluated. Hypnotic drugs could alter the sleep state. The central nervous system active medicines often alter the occurrence, latency of specific sleep and dream state, with either therapeutic intent or side effects . In addicelecoxib group), whereas the other will not (control group).The objective of this study is to evaluate the effects of additional postoperative celecoxib administration on pain after TKA surgery. All patients will routinely receive a combination of femoral/sciatic nerve blocks and postoperative fentanyl PCA and be randomized using a computer-generated list to one of two groups, one of which will receive immediate postoperative celecoxib , Tsukuba Critical Path Research and Education Integrated Leading Center (CREIL center) Tsukuba Clinical Research and Development Organization (T-CReDO), University of Tsukuba.In accordance with the package insert, and as in a previous study , the firSurgery will be performed under general anesthesia. After general anesthesia is induced, a single injection of peripheral nerve blocks, consisting of 25 ml of 0.375 % ropivacaine hydrochloride as a femoral nerve block and 25 ml of 0.2 % ropivacaine hydrochloride as a sciatic nerve block, will be administered under ultrasound guidance.Postoperative analgesia will consist of PCA with fentanyl citrate. At the end of surgery, the PCA pump will be started at a basal rate of 10 μg per hour. An on-demand mode will be programmed, allowing for bolus injections of 15 to 20 μg every 5 minutes, with the maximum basal and bolus doses allowed per hour being 250 μg.Patients who require an additional analgesic after PCA fentanyl removal on the second day after surgery will be allowed a 25 or 50 mg diclofenac sodium suppository. Usage of the rescue analgesic will be recorded.The primary outcome measure in this study will be patient-reported VAS pain score at 9 o’clock on the second day after TKA. This measure will allows us to identify the effect of early administration of celecoxib Table .Table 1DFor secondary outcome measures, fentanyl consumption through PCA is assessed at 2 days after surgery; VAS pain score is assessed at 9 a.m. each day from 1 to 7 days after surgery; range of motion of the knee joint is assessed at 9 a.m. at 2 and 7 days after surgery; postoperative sleep quality is evaluated at 1, 2 and 7 days; overall patient satisfaction during the period of medication is evaluated at 7 days after surgery; overall evaluation by the physician during the period of medication is assessed at 7 days after surgery; incidence rates of postoperative nausea and vomiting and frequency of taking anti-nausea pills is assessed for the 7 days after surgery; and consumption of rescue analgesics (diclofenac sodium suppositories) after the discontinuation of PCA fentanyl is assessed overall for the 7 days after surgery  . SLEEPSCAdministration of study drugs will be immediately stopped in participants who show relevant deterioration. Severe adverse events, as determined by the Common Terminology Criteria for Adverse Events (CTC-AE) ver. 4.0, will be reported to the principal investigator, who will report any unexpected serious adverse reactions to the institution.Data collection across time points is shown in Table The validation of collected data for this cohort is important. Previously, patient-reported VAS pain score has been well validated –14. BecaThe primary outcome of this study is patient-reported VAS pain score on the second day after surgery, based on the hypothesis that immediate postoperative administration of oral celecoxib could reduce patient-reported VAS pain score 48 hours after TKA surgery compared with the control group.Sample sizes are chosen to detect clinically relevant differences using a power analysis based on previously published data evaluating the effect of celecoxib on VAS pain score after TKA . The minThe intention-to-treat analysis will be conducted for all patients who underwent randomization. Baseline information on study subjects in two treatment groups such as demographics, preoperative VAS pain scores, ranged of motion and sleep quality will be described. The primary outcome that the differences of VAS pain scores between celecoxib and control groups at the second day after surgery will be analyzed by ANOVA. The secondary outcomes including the pain-medication use, adverse reactions, VAS pain scores, range of motion of knee joint, sleep quality, patient satisfaction, and overall evaluation by physicians after surgery will be analyzed by ANOVA or Chi square test. Nonparametric tests may be used for continuous variables if they are not normally distributed. Between-group comparisons of treatment effect for primary and secondary outcomes, except for pain-medication use and adverse events, will also be conducted with the use of a mixed-effects model, with patient as a random effect and time of assessment (baseline and follow-up days), study group, and baseline values of the outcome as fixed effects.P < 0.05. All statistical analyses will be performed by using SAS 9.4 .Significance will be set as To achieve less postoperative pain, better patient satisfaction, and better rehabilitation after surgery, pain management is very important. Multimodal analgesia for pain management after surgery has been shown effective in controlling postoperative pain . PreviouCOX-2 inhibitors and other NSAIDs have only been approved as postoperative, but not as preemptive, analgesia in Japan. In addition, an appropriate fasting period to empty the stomach prior to anesthesia is essential for patient safety, because the risk of inhaling stomach contents into the lungs is reduced. Thus, to verify the effectiveness of administration of a COX-2 inhibitor during the early postoperative period as part of multimodal analgesia, it is necessary to establish clinical practice guidelines. In addition, this method of administration is safe, convenient and general-purpose way in practice. To date, however, no comparative data are available.This randomized controlled trial design will be used to address the hypothesis, that immediate administration of oral celecoxib after TKA surgery provides superior postoperative analgesia when compared with delayed administration.The primary outcome of this study is to evaluate the effects of celecoxib administration immediately after surgery on postoperative pain after TKA. Possible benefits of celecoxib include its ease of administration, safety after surgery, its effectiveness and reduction of postoperative opioid consumption. Thus, this study might to identify the influence of immediate administration of oral celecoxib after TKA surgery. This will help to provide clinical management status for patients with TKA surgery.Opioid consumption for the secondary outcomes will be determined. Opioid is useful and effective for postsurgical pain control. However, the incidence rates of postoperative nausea and vomiting as its side effects could be increased with large amounts of opioid. By taking medicine for pain relief after the early post-operative period, opioid consumption and its side effects could be reduced. As its other expectations, pain relief after surgery might improve the quality of sleep. When postoperative pain is reduced, the range of knee motion with accelerated physical recovery might be improved. Pain relief, good quality of sleep and early functional recovery could improve satisfaction of patients. These will be very important to establish clinical practice guidelines.The limitation of this study is an open label. However our data will come from patient-reported outcomes and participants will not be affected by any other. Patient–reported outcome will help to understand practical patients’ condition. Therefore, we believe that this study will provide some insight into perioperative multimodal analgesia, which helps to improve perioperative clinical practice.This randomized controlled trial will help to provide insight to optimize perioperative pain management strategies by evaluating the effect of immediately postoperative administration of analgesics for patient after TKA surgery. These results could improve clinical practice for perioperative pain management and also might help to improve patient satisfaction.Patient recruitment started in October 2014. The predicted study completion date is March 2016.


Intra-articular corticosteroid injections (IACI) are routinely used by pediatric rheumatologists in the treatment of chronic arthritis. Frequently, topical anesthetics are used to control procedural pain, but their relative efficacy has not been reported. In this study, we evaluated the level of pain associated with different anesthetic methods, Numby® 900 Iontophoretic Drug Delivery System, or EMLA® cream, with or without subcutaneous buffered lidocaine (SQBL), during IACI of the knee in children with arthritis.We conducted a prospective study of patients, ages 4 to 21 years old, followed at three pediatric rheumatology centers who were undergoing IACI of a knee joint. Patients were randomized into two treatment groups: 1) topical anesthetic only (EMLA® or Numby® (E/N)), or 2) topical anesthetic (E/N) and SQBL. Pain was assessed at baseline, during topical anesthetic placement, and following the IACI (post-procedure). The Faces Pain Scale-Revised (FPS-R), the Face, Leg, Activity, Cry, Consolability (FLACC) behavioral scale and the parental global assessment (PGA)  were determined.P = 0.03), FLACC (P = 0.02) and PGA (P = 0.01) scores were significantly lower in females treated with E/N plus SQBL compared to patients treated with E/N only. Females in the E/N only group had a significant worsening of their baseline pain (p < 0.0004) and a greater magnitude of change in their baseline FPS-R scores (p < 0.001) from the procedure compared to females in the E/N plus SQBL group who had no worsening of their baseline pain. No significant change in pain level or PGA score was found among males in either treatment group. Pain scores overall were similar to the oligoarthritis patients, a more homogeneous group of patients. Both EMLA® (n = 33) and Numby® (n = 29) were equally well tolerated with no significant difference in median FPS-R administration scores overall.Sixty-three patients  with a median [IQR] age of 10.8 [IQR = (8.2–14.4)] years (range 4.7–20 years) with active knee arthritis were consented. FPS-R post-procedure (Our results suggest that a topical anesthetic plus SQBL is more effective for injection pain control than topical anesthesia only. Further studies addressing pain and anxiety will help determine the optimal method of pain control for IACI. Intra-articular corticosteroid injections (IACI) are one of the mainstays of treatment for patients with chronic arthritis and are part of the 2011 American College of Rheumatology recommendations for the treatment of juvenile idiopathic arthritis (JIA) . IACI enDespite the frequent use of IACI, little attention has been paid to the pain and distress that may be associated with the procedure, and there is no established standard regarding the type of anesthesia to use for IACI. Both biological  and psychological factors contribute to the fear and perception of pain and pain scores . MinimizLocal anesthesia for IACI may include topical preparations such as EMLA® cream  or LMX-4  , 3, lidoTo determine the methods of local and general anesthesia currently being used by pediatric rheumatologists, a survey was conducted in 2006 of all members of the Childhood Arthritis & Rheumatology Research Alliance (CARRA), a major research collaborative organization of pediatric rheumatologists in North America . Fifty-nThe anesthetic effect of EMLA® versus lidocaine iontophoresis for IACI has not been studied, nor is it known whether the addition of subcutaneous buffered lidocaine (SQBL) is beneficial. Our objective in this open-label prospective, randomized trial was to determine the optimal method of delivering local anesthesia for IACI by comparing two treatment groups: Numby® 900 Iontophoretic Drug Delivery System or EMLA® cream with or without subcutaneous buffered lidocaine (E/N + SQBL) or E/N only.Patients between 4 and 21 years of age with JIA or Lyme arthritis with chronic, active arthritis of at least one knee and who were prescribed an IACI were eligible for participation in the study and enrolled between April 2006 and November 2008. Exclusion criteria included: 1) allergy to lidocaine or any ingredient used in Numby® or EMLA®, 2) use of an electrically sensitive support system , 3) damaged skin or signs of infection at the proposed injection site, 4) coagulopathy, or 5) inability to evaluate pain associated with the procedure.This study was approved by the Institutional Review Boards of Hackensack University Medical Center, Hackensack, NJ, St. Barnabas Medical Center, Livingston, NJ and Connecticut Children’s Medical Center, Hartford, CT. Written informed consent from parents and written informed assent when child >9 years old were obtained.The Faces Pain Scale-Revised (FPS-R) is a self-report measure consisting of 6 gender-neutral faces depicting increasing intensity of pain that corresponds to a 0–10 metric pain scale . Studies have demonstrated that the FPS-R correlates highly with other self-report pain scales and children ≥4 years of age are able to use the scale . AlthougPatients were randomized into one of four groups. Group 1 had 2.5 g of EMLA® applied with occlusive dressing  for 60 min. Group 2 had 2.5 ml of the lidocaine hydrochloride 2 % and epinephrine 1:100,000 topical solution placed on the Numby® 900 electrode pad and then placed on the patient at the injection site for 20 min. The dispersive pad was placed over a major muscle group 10–15 cm away from the drug electrode. Numby® 900 was started at 2.0 mA for 20 min. Group 3 had EMLA® applied as above plus an injection of SQBL (9:1 2 % lidocaine to sodium bicarbonate). Group 4 had Numby® 900 applied as above plus an injection of SQBL.A FPS-R score was obtained from the patient at 3 time points: 1) upon arrival to the office (FPS-R baseline), 2) once the topical anesthetic was removed, before the needle was inserted  to reflect discomfort from the anesthetic and 3) at completion of the procedure (FPS-R post-procedure) to reflect procedure pain. A FLACC score and PGA were recorded.Parents were present during the procedure. A child life specialist or experienced nurse was present to provide psychosocial support, distraction and to improve patients’ and parents’ understanding of the procedure. After the skin was sterilized with povidone-iodine and alcohol, a 21 gauge needle on a 3 ml syringe was inserted into the joint space through a medial approach. In the SQBL group, the syringe was filled with buffered lidocaine and the periarticular space was slowly infiltrated at physician discretion. The needle was then advanced into the joint space, syringe was then replaced with a sterile empty syringe and the synovial fluid was aspirated. With the needle remaining in place, the contents of a syringe containing 1 mg/kg (maximum 100 mg) of triamcinolone hexacetonide was injected.Continuous random variables were summarized as mean (standard deviation) or median (inter-quartile range) depending on whether or not the data followed the normal distribution. Categorical responses were presented as frequencies (percentages). With a two-tailed test with significance level of 5 % and a defined clinically significant difference of 1.5 standard deviations on the primary outcome, pain, and power of 80 %, we calculated that a sample size of 72 patients (18/group) was required. Because this target was not achieved, we aggregated the four treatment groups into two treatment groups a) patients who received EMLA® or Numby® only (E/N) and b) patients who received EMLA® or Numby® plus SQBL (E/N + SQBL). Continuous variables, age, disease duration, pain scores and global assessment were not normally distributed as indicated by the Shapiro-Wilk test. Hence, comparisons between any two groups were conducted using a Wilcoxon rank sum test. Comparisons of two groups with respect to categorical variables, gender, disease type, were performed using Chi-square test or Fisher Exact test as appropriate.Subgroup analysis of pain scores was conducted in the cohort of oligoarthritis patients, the most common JIA subtype and a more homogeneous group of patients. Females reportedly have higher pain scores , so compSeventy-seven patients were approached for the study and 63 (44 girls) Table  agreed tn = 28), the median FPS-R baseline score was 0.0 [IQR = (0.0 to 2.0)] and the median FPS-R post-procedure score was higher at 3.0 [IQR = (2.0 to 6.0)]. In the E/N plus SQBL group (n = 35), both the median FPS-R baseline score and FPS-R post-procedure score were 2.0 [IQR = (0.0 to 4.0)] and 2.0 [IQR = (1.0 to 4.0)], respectively. A comparison between patients in the two treatment groups using the FPS-R post-procedure and FLACC scores did not reveal any significant differences. There was a significant difference in the PGA (P = 0.005).In the E/N only group (P = 0.03) with 21 % of patients having severe pain (FPS-R score 7.0–10.0) , FLACC (P = 0.04) and PGA (P = 0.005) scores, subsequent comparisons between treatment groups were performed within each gender (Table n = 19) in the two treatment groups did not have a significant difference in median pain or PGA scores. These findings held true even when the more homogenous group of oligoarticular JIA patients were compared , therefore, comparisons were performed within each gender. With the exception of the FLACC scores in males, those patients who had a prior IACI did not experience worse pain compared to patients who never had a prior IACI, independent of their gender (P > 0.05).Nineteen patients (31 %) (13 F) had a prior IACI. The Friedman rank test revealed a significant interaction between gender and prior IACI with the FPS-R (p = 0.0004) of their baseline pain (pain related to their active arthritis) by 2 points compared to the females in the E/N plus SQBL group that had no worsening of their baseline pain from the procedure (Table p = 0.001) (results not shown). No significant change in pain level was found among males either between or within treatment groups.Table re Table . Within n = 33) and Numby® (n = 29) were equally well tolerated with no significant difference in median FPS-R administration scores overall. Adverse events were minor. In the Numby® 900 group, they included: blanching (n = 17), redness (n = 13), and complaints of “tingling” (n = 14), “itching” (n = 7), “pain” (n = 6), and “burning” (n = 4). In the EMLA® group, they included blanching (n = 21), redness (n = 9), and complaints of “itching” (n = 1).Both EMLA®  in pain scores, in which the patient would find the procedure pain tolerable. Prior studies have shown a 2 point change in score out of 10 points (or 1 face) on the FPS to be clinically significant . Our stuA contributing factor to our low pain scores may be our use of a child life therapist during the procedure. Child life therapists play an important role in helping patients cope with anxiety and procedure pain by reassuring and distracting them and by employing relaxation techniques. Studies have shown that developmentally appropriate behavioral and cognitive pain management strategies  are often effective in pain control , 17. WeiBuffering the lidocaine, which is acidic (pH 3.5–7), with sodium bicarbonate and administering slowly is also an important step in reducing procedural pain as it reduces the burning sensation associated with its infiltration into skin (pH 7.35–7.45) . A CochrBoth topical anesthetics were well tolerated with no significant difference in FPS-R administration scores. Blanching was the most common side effect of both agents which is to be expected due to their vasoconstrictive properties. Our patients tolerated the electric current from the lidocaine iontophoresis which was an important finding since this modality has a faster onset of action and a greater depth of penetration than EMLA® cream. A study looking at determinants of success and failure of EMLA® found that while EMLA® has proven to be safe, it seems to offer less pain control, at least when applied for 60 min, compared to iontophoresis . It is rThere were several limitations of our study including small sample size, open-label, and age of our study population. The number of patients needed to adequately power this study was not achieved. The median patient age in our study was 10.8 [IQR = (8.2 to 14.4)] years, so expanding the study to include a greater number of younger children would be useful to determine if our findings are applicable to children less than 5 years of age. This study was not blinded and therefore the patient may have a biased response to their treatment based on the physician’s or nurse’s attitudes about the anesthetic used. Normal synovium may be up to 45 mm thick, but inflamed synovium can be significantly thickened . This caIACI are routinely used by pediatric rheumatologists and since patients frequently need repeat injections, it is important to identify strategies that minimize pain to better ensure patient cooperation and compliance with the current and future procedures. Our results suggest that the addition of subcutaneous buffered lidocaine to a topical anesthetic is an improvement over topical agents alone, especially in females. Future studies addressing pain and anxiety around IACI are needed to establish the best practices for performing IACI.


To investigate the possible association between the serotonin transporter gene (5-HTTLPR) and rs 25531 polymorphism and the susceptibility and the pain severity in Trigeminal Neuralgia patients.A total of 244 TN patients and 280 age and sex matched healthy volunteer were recruited. 5-HTTLPR and rs 25531 genotyping were performed. All patients received the carbamazepine treatment and the treatment response was evaluated at 6 months.The genotype distribution of 5-HTTLPR between TN patients and controls were significantly different. The TN Patients had a higher prevalence of short-short genotype than controls. The short-short genotype carriers are also significantly associated with higher pain severity and poorer carbamazepine treatment response compared to the long-long genotype carriers. In contrast, the rs 25531 polymorphism was not associated with the susceptibility to TN, neither with the pain severity and the treat response to carbamazepine.The 5-HTTLPR polymorphism is associated with the susceptibility to TN and pain severity of TN. Trigeminal neuralgia (TN) is the most common type of neuralgia in human adult ,2. TN isSerotonin  is an important neuromodulator associated with a wide range of physiological effects in the central nervous system. Previous studies have revealed a critical role for 5-HT in numerous physiological processes, including cell division, neuronal migration, differentiation and synaptogenesis. 5-HT has been implicated in a series of pain disorders including migraine, temporomandibular pain and pain conditions mediated by the trigeminal system -12. SeroSLC6A4 gene whose transcriptional activity is regulated by a number of variations [5-HTT protein is encoded by the riations ,14. The riations ,16. Receriations . The 5-Hriations . In patiriations .To date, there is no study reporting the association between 5-HTTLPR and the susceptibility to TN and its clinical features, especially the pain severity and treatment response to analgesics. Based on the role played by the 5-HTTLPR gene polymorphisms in other pain conditions ,18, we pThis study included 244 patients diagnosed with idiopathic TN who were treated at Pain department of the First Affiliated Hospital, China Medical University from August 2008 to August 2012. The TN diagnosis was established according to the International Association for the Study of Pain (IASP) . All patAll patients were treated with the traditional approach of CBZ in monotherapy  for 6 months. Patients who discounted the treatment or went to interventional or surgical treatments within 6 months were excluded. The degree of pain was checked using Barrow Neurological Institute .Genomic DNA was extracted from participants' peripheral blood leukocytes using a DNA extraction kit . The promoter region of the SLC6A4 gene was amplified using a 10 μl of PCR reagent mixture with a forward primer set of 0.25 μM VIC-labeled and 0.25 μM unlabeled, and 0.50 μM reverse primer and 250 μM dNTP on the GeneAmp PCR System 9700 . Here, 526 bp and 478 bp fragments were called as a Long and a Short allele at 5-HTTLPR, respectively. For the rs25531 polymorphism, the PCR product was digested with restriction endonuclease MspI . The resulting product was analyzed using an ABI3100 DNA Analyzer and the Peak Scan Software v1.0 (Applied Biosystems). Digested fragments with a size of 164–165 bp were determined as a G allele and indigested as an A allele.The Fisher's exact Chi-square test was first used to compare the frequency distribution of age, gender, smoking status between TN patients and controls, if appropriate. A chi square test was performed to assess Hardy–Weinberg equilibrium in the TN patients and controls based on allelic and genotypic frequencies. We performed multivariate logistic regression analysis to estimate the effect of 5-HTTLPR or rs25531 polymorphisms on risk factor for TN in the presence of other known prognostic factors, including age, sex and smoke. Analyses were performed using the software SPSS 16.0 . All P values were two-sided, and a P value < 0.05 was considered significant.The characteristics of patients and controls are listed in Table The genotype distribution of 5-HTTLPR between TN patients controls are presented in Table Before starting treatment, the TN patients were then divided into two groups according to the pain severity: those with severer pain severity (BMI grade: IV-V) and those with less pain (BMI grade: I-III). TN Patients with higher BNI scores had a higher prevalence of 5-HTTLPR short-short genotype and short allele than those with lower BNI scores  and drug transporters (MDR1) are associated with the therapeutically response to analgesics in pain condition ,38. The The other limitations of this study should also be addressed. Several limitations should be addressed in this study. Firstly, this is a singe center study with a relatively small size of patient sample. Thus the enrollment bias may occur. Secondly, this study did not go deep to explore the molecular mechanism under which the 5-HTTLPR genotype influences the TN risk and treatment response.All authors declare that they no competing interest.WC: acquisition of data, analysis and interpretation of data; drafting the manuscript. XY: Polymorphism analyses, collection of data. WC and HZ, Polymorphism analyses, collection of data. WC and XY: conception and design, revising the manuscript. All authors read and approved the final manuscript.


Pain is the most common complication of orthodontic treatment. Low-level laser therapy (LLLT) has been suggested as a new analgesic treatment free of the adverse effects of analgesic medications. However, it is not studied thoroughly, and the available studies are quite controversial. Moreover, helium neon (He-Ne) laser has not been assessed before.2 density). The other quarter served as the placebo side, treated by the same device but powered off. In the first, second, fourth, and seventh days, blinded patients rated their pain sensed on each side at home using visual analog scale (VAS) questionnaires. There was no harm identified during or after the study. Pain changes were analyzed using two- and one-way repeated-measures ANOVA, Bonferroni, and t-test . This trial was not registered. It was self-funded by the authors.This split-mouth placebo-controlled randomized clinical trial was performed on 16 male and 14 female orthodontic patients requiring bilateral upper canine retraction. The study was performed at a private clinic in Sari, Iran, in 2014. It was single blind: patients, orthodontist, and personnel were blinded of the allocations, but the laser operator (periodontist) was not blinded. Once canine retractor was activated, a randomly selected maxillary quarter received a single dose of He-Ne laser irradiation . One-way ANOVA showed significant pain declines over time, in each group (P < 0.0001). Two-way ANOVA showed significant effects for LLLT (P < 0.0001) and time (P = <0.0001).Sixteen males and 11 females remained in the study (aged 12–21). Average pain scores sensed in all 4 intervals on control and laser sides were 4.06 ± 2.85 and 2.35 ± 1.77, respectively (Single-dose He-Ne laser therapy might reduce orthodontic pain caused by retracting maxillary canines. The most common sequela of orthodontic treatment and one of its most significant problems is pain and discomfort –8. Its iVarious methods have been proposed to relieve orthodontic pain. According to recent reviews, the most effective approach is the administration of non-steroidal anti-inflammatory drugs (NSAID) , 11, 15.Owing to unique advantages in bio-stimulation, pain relief, therapeutic effects, and lack of adverse effects, low-level laser therapy (LLLT) has attracted increasing attention in recent years , 11, 15.An issue with the methods was that most studies evaluated pain invoked by local separator placement , which cEvaluating subjective phenomena like pain is a challenge, since it varies considerably between patients and even between different times in a single patient . The besFurthermore, all previous studies have evaluated aluminum-gallium lasers. There is no study on helium-neon (He-Ne) lasers. Therefore, we aimed to conduct this split-mouth clinical trial on the analgesic effect of a single-dose He-Ne laser irradiation on pain caused by canine retraction. The null hypotheses were the absence of any differences between the pains felt at laser or placebo sides as well as the absence of any changes in pain levels over time.This single-blind split-mouth placebo-controlled randomized clinical trial was performed  on 60 bilateral maxillary canines retracted in 30 orthodontic patients .The ethics were approved by the university’s research committee, in accordance with the Helsinki declaration. This trial was not registered. Subjects or their parents were thoroughly briefed written and orally. Subjects could leave the study at their wish in any stage. They signed written consent forms.The patients and the operator wore protective goggles. No harms were identified during the study, except for those being a routine part of the process of canine retraction (pain and discomfort).The patients were selected from attendees to a private orthodontic clinic in Sari, during 2013. The subjects were sequentially acquired until reaching the predetermined sample size.The inclusion criteria comprised the subjects’ willingness to participate, the indication for bilateral canine retraction (through the extraction of maxillary first premolars), the absence of any systemic diseases or mental disorders , any history of medication intake as of 4 days before the treatment, any local or systemic condition affecting or inducing pain, as well as no history of previous orthodontic treatment of any kind. Patients were excluded if they did not return the completed questionnaires, used any analgesics during the trial period, were not available at the scheduled phone call, and if the treatment was interrupted , 30–32.In this split-mouth design, each patient had a treatment side  and a placebo side (simulated laser therapy) simultaneously. These sides were randomly pre-assigned in each patient, based on a random number table, by a periodontist who was the only person knowing the allocations .The patients, orthodontist, and personnel were blinded of the allocations. The results were coded. During the irradiation, personnel would leave the room, so only the periodontist would know the allocations . Patients were not told of the experimental side. The placebo was the simulation of irradiation with the same duration but with the device turned off. Therefore, patients could not distinguish the placebo/experimental sides. Since the data were coded, the statistician did not know the grouping as well.Orthodontic treatment plan included extraction of upper premolars for crowding correction or treatment of maxillary dental protrusion. Patients were treated using metal pre-adjusted brackets of slot 0.022 in. . After banding and bracket bonding, the stages of aligning and leveling were started. According to common treatment sequence, this treatment stage was done by nickel titanium archwires  with diameters of 0.014, 0.016, and 0.018 in.After finishing the aligning and leveling stages, canine retraction began using 0.018-in-stainless steel wires containing offset for canines, molar toe in and tip back in the mesial side of first molars. For more anchorage preservation, second molars were banded and engaged in wires in both sides. A closed power chain  was used to apply forces of 150–175 g. Both sides were treated in the same session and immediately after each other. The side to begin the canine retraction with (left or right) was selected randomly as stated above. This randomization was absolutely independent of the randomization of the laser treatment side (left/right) and its order (being performed first or second). The force was standardized between both sides and among all patients, using a force gauge. All the canine retraction (and laser irradiation) procedures were performed at evening sessions (between 17 and 20 o’clock).2. The tip diameter was 5 mm. From the tooth CEJ to the end of the root apex, irradiation was separately done from the buccal and palatal. During the irradiation, the tip was directed perpendicular to the long axis of the tooth. Since the thickness of alveolar bone is greater over the apical part of the root, the duration of irradiation was decided to be as twice longer in the apical one half of the root, compared to its coronal half. Therefore, radical apical and coronal halves were irradiated for 40 and 80 s, respectively . The phototherapy of each root section  was performed by a slow up-and-down movement of the device tip in a gentle touch with soft tissue, within the predetermined duration. The amount of laser irradiated at each point was standardized by the constant speed of the device tip being moved on the desired root section/side.All the experiments were performed in a single location and in the evening. In the experimental side, laser irradiation was conducted as follows: A single dose of laser emission was applied immediately after the initiation of force exertion. The used laser was He-Ne of red color (632.8 nm) emitted at a 10-mW power and an energy density of 6 J/cmIn the placebo side, the phototherapy was simulated [pretended] in terms of timing and every procedural detail with the same equipment, however, turned off. The patient was unaware of the placebo and experimental sides as well as the order of performing laser/placebo treatments.In each patient, the pain was assessed on each side of the mouth using a visual analog scale (VAS). The patients were thoroughly instructed regarding filling VAS for left and right sides. A written instruction was as well given to them. The evaluations were done at home, on the first, second, fourth, and seventh days after imposing the force. Patients were called on their landline and/or mobile phones after 24, 48, 96, and 168 h after the treatment. On the phone, they were reminded of filling their VAS questionnaires.The VAS was converted to 10 distances of equal length, between the 11 scores of 0–10. The score zero meant the absence of any pain/discomfort. The score 10 meant any pain considered intolerable by the patient OR causing the patient to seek emergency visits OR waking them from sleep .n = 216 measurements, α = 0.01, mean difference = 1.213 ± 1.326). The difference between the control and experimental groups was assessed using a paired t-test of the SPSS program . Repeated-measures one- and two-way analyses of variance (ANOVA) and a Bonferroni post hoc test were used to assess the effects of treatment and time on pain. The level of significance was set at 0.01.Descriptive statistics for pain levels, as the outcome, were calculated. The sample size was predetermined based on a pilot study of 17 patients, to obtain powers greater than 90 %. It sufficed to provide post hoc test powers greater than 99 %  aged 12–21 years (mean = 15.3).t-test showed a significant difference between the pain level senses on each side (P < 0.0001). The paired t-test also detected significant differences between the treatment/placebo groups, at each of time intervals . The Bonferroni test showed significant differences between each of the intervals .The one-way repeated-measures ANOVA showed a significant overall time-dependent decline in pain perceived in the placebo side . All pairwise comparisons were significant .The time-dependent pain decrease was significant in the laser side as well (ANOVA P < 0.0001) and time (P < 0.0001) were significant. The interaction of the variables “time and treatment” was not significant (P = 0.022). According to the Bonferroni post hoc test, all pairwise comparisons were significant . On the healing . The dif healing . Mechani healing . Perhaps healing , 42–46.  healing . Other f healing , 48. Als healing , 49.This study was limited by some factors. Pain is subjective, and numerous factors  can affect it , 46, 32.Some studies did not exclude patients taking analgesics and only monitored the number of analgesics taken . HoweverSingle-dose low-level laser therapy might reduce orthodontic pain caused by retracting maxillary canines. Regardless of the presence or absence of laser therapy, orthodontic pain might considerably decrease after a week, although not completely eliminated in this period.


Pulsed radiofrequency (PRF) treatment is defined as the delivery of short pulses of radiofrequency via a needle tip, which does not result in an actual thermal lesions. There are mixed views regarding the use of PRF for trigeminal neuralgia (TN). In our opinion, one of the main reasons for the contrasting views is the insufficient PRF dose employed in previous studies. In a recent study on the effects of PRF on resiniferatoxin-induced neuropathic pain in an animal model, the anti-allodynic effects of PRF were significantly greater when the PRF exposure duration was increased from 2 to 6 minutes.The primary objective of this retrospective study is to report the results for 36 consecutive patients who underwent PRF treatment for TN, for 6 minutes at 45 V at a pulsed frequency of 4 Hz and a pulse width of 10 ms.For the study, we obtained procedural records of 36 consecutive patients. Their current state of pain was evaluated over a telephonic survey and the post-procedural data at 2, 6, and 12 months were retrieved thereafter from the patient records. The main outcome measure was excellent pain relief (more than 80%), which was assessed at 2, 6, and 12 months.The percentages of patients who showed excellent pain relief (> 80% pain relief) at 2, 6, and 12 months were 73.5% (25/34), 61.8% (21/34), and 55.9% (19/34), respectively. The percentages of patients showing satisfactory pain relief (50–80% pain relief) at 2, 6, and 12 months were 14.7% (5/34), 17.6% (6/34), and 17.6% (6/34), respectively, and those of patients showing less than satisfactory pain relief (< 50% pain relief) at 2, 6, and 12 months were 11.8% (4/34), 20.6% (7/34), and 23.5% (8/34), respectively. No complications were reported, and none of the patients required hospitalization.PRF of the trigeminal ganglion should be further evaluated as an alternative treatment method for TN. The International Headache Society classifies trigeminal neuralgia (TN) into classical and symptomatic TN, with the latter being clinically indistinguishable from the former. The only identifiable difference between the 2 conditions is that in symptomatic TN, a causative lesion (other than vascular compression) can be detected, and has been demonstrated in imaging or posterior fossa exploration  . In clinCarbamazepine is the drug of choice in the initial treatment of idiopathic TN. However, some patients develop adverse effects while some others do not show sustained pain relief . For casPulsed radiofrequency (PRF) treatment is defined as the delivery of short pulses of RF via a needle tip, thereby avoiding thermal lesions. This technique had been performed for various other conditions and has been shown to be effective and safe. There are contrasting opinions regarding the use of PRF treatment for TN, , 15 but In a recent study on the effects of PRF on resiniferatoxin-induced neuropathic pain in an animal model, the anti-allodynic effects of PRF were significantly greater when the PRF exposure duration was increased from 2 to 6 minutes . We presInstitutional research review board approval was obtained prior to the retrospective collection of patient data. All patients presenting at our hospital with refractory facial neuralgia undergo a multidisciplinary assessment, including complete neurological evaluation and magnetic resonance imaging (MRI). This retrospective study included all 36 patients who underwent lateral trigeminal ganglion PRF treatment for typical and atypical TN at a single pain centre from January 2007 to April 2009. All the therapeutic procedures were performed by 2 pain physicians at our pain centre. A referring neurologist excluded secondary causes of the pain after studying MRI reports. All 36 patients presented with lancinating, burning, or aching unilateral severe facial pain, in one or more of the trigeminal nerve distributions; a small proportion of patients also experienced chronic background pain. Typical trigger points on the face in one or more of the trigeminal nerve distributions were observed in both patients with typical and atypical TN. Distinct triggering stimuli or activities such as touch, cold wind on the face, chewing, talking, and yawning were also commonly reported. Many of the painful episodes or paroxysms lasted from minutes to hours, but the episodes rarely lasted for days. Some patients reported that initial treatment with drugs such as carbamazepine, phenytoin, or gabapentin was effective, but their pain relief was rarely sustained.et al.  less than 50% relief; b) 50–80% pain relief; c) more than or equal to 80% pain relief. The data entry was performed by another assistant who was not involved in the design of the study or in the analysis of the data. Descriptive statistics were generally reported as mean ± SD. Frequency counts were used to summarize categorical data. All statistical analyses were performed using the SPSS software package for Windows (version 16.0).Table 1. The distribution of the affected trigeminal branches is shown in Figure 2.The pain centre procedural records showed that 36 patients had undergone PRF treatment on the trigeminal ganglion from January 2007 to January 2009. A mean duration of 2.3 ± 0.8 years have elapsed since the last PRF procedure in this group of patients, of which 67.6% still reported satisfactory pain relief. Of these 36 patients, 1 died and 1 underwent a neurosurgical procedure soon after the PRF and was unwilling to participate in the evaluation. The remaining 34 patients consented to the use of their retrospective data for analysis. The baseline characteristics of the 34 patients are shown in From the retrospective review of the documented clinical results of all 34 patients, the percentages of patients who showed excellent pain relief (≥ 80% pain relief) at 2, 6, and 12 months were 73.5% (25/34), 61.8% (21/34), and 55.9% (19/34), respectively. The percentages of patients with satisfactory pain relief (50–80% pain relief) at 2, 6, and 12 months were 14.7% (5/34), 17.6% (6/34), and 17.6% (6/34), respectively, and those of patients showing less than satisfactory pain relief (< 50% pain relief) at 2, 6, and 12 months were 11.8% (4/34), 20.6% (7/34), and 23.5% (8/34), respectively. No complications were reported, and none of the patients required hospitalization.To our knowledge, this is the largest series of TN patients treated with PRF. Among these patients, 67.6% continued to report satisfactory pain relief after 2.3 ± 0.8 years of PRF treatment. This data correlated well with our records of excellent and satisfactory rates of pain relief at 6 and 12 months. This may mean that good pain relief at 6–12 months after trigeminal ganglion PRF treatment may predict for long-term efficacy using PRF treatment. The affected trigeminal branch distributions in all 34 patients in our series were similar to those reported in the literature , 17.et al. (In a prospective case series, reported by Van Zundert et al. , 5 high-et al. (et al. (In the largest review till date, Kanpolat et al.  reported (et al.  demonstrSimilar to RF, if more than 1 branch of the trigeminal nerve is affected, PRF application to other affected trigeminal distributions is equally important.In our experience, PRF treatment with a pulsed width of 20 ms and frequency of 2 Hz for 2 minutes is insufficient for TN.The authors in that trial used the well-accepted meticulous process of conventional RF of the trigeminal ganglion. RF thermocoagulation at 70 °C for 60 s was carried out, and the sensitivity of the affected area of the face and cornea were tested thereafter. If more than 1 branch of the TN was affected, second or more procedures were performed by repositioning the needle tip and waiting for paresthesia after each procedure. Such a meticulous process, however, was not described for PRF. It appears that they performed a PRF treatment procedure, wherein 2 bursts of 20 ms were applied for 120 s at an output of 45 V . Notwithet al. (withdrawal latency-increased anti-allodynic effects, than the groups with 2 or 4 minutes of PRF application.In the case series by Van Zundert et al. , 1 patieet al. . The groA systematic review of ablative neurosurgical techniques for the treatment of TN evaluated 166 studies reporting RF thermocoagulation, glycerol rhizolysis, balloon compression of the trigeminal ganglion, and stereotactic radiosurgery and concluded that RF thermocoagulation offers the highest rates of complete pain relief . In our The limitations of this study are inherent to retrospective studies of such nature, in which data have been collected in a clinical context and cannot, for example, allow quantification of the changes in pain medications over 1 year of follow-up. PRF treatment of the trigeminal ganglion may be a possible alternative to minimally invasive treatment in the management of TN. The possibilities of reduced heat-related complications and comparable efficacies to conventional modalities need to be evaluated in greater detail in further studies.


In 32 years of practice, I have seen vast improvement in the treatment of patients with cancer. From the introduction of novel therapeutic treatments to the approval of innovative pain medications, our patients with cancer have benefited from the approval of new therapies. I eagerly anticipated new forms of medications for pain, as sustained-release forms of old standards offered better pain relief and easier administration for our patient population. The introduction of the fentanyl patch and sustained-release oxycodone was welcomed in my practice, as we sought to obtain better pain relief for our patients. National and federal guidelines reported new pain management standards over two decades ago, bringing heightened awareness of this debilitating symptom to the health-care professional (HCP). And yet, despite the potential for improved pain management made possible by the new drug formulations and inventive new agents, patients still report pain during their experience with cancer.There are myriad reasons for possible undertreatment of pain in our population of patients with cancer. A pivotal paper published in 1994 reported that pain is the most persistent and devastating symptom for patients with advanced disease and that both HCPs and patients described this symptom as often poorly managed . The authors of this paper conducted a study of 1,308 patients and determined that although multiple factors play a role in predicting inadequate pain management, 42% of their study participants were not given adequate analgesic therapy. Centers treating minorities had even higher rates of poor pain control, as patients were three times more likely to report inadequate management .The prevalence of pain in patients with cancer remains significant. A meta-analysis published in 2007 reported that cancer pain remains a major concern for this population of patients . Patients with advanced disease had the highest incidence (64%), but 59% of patients on anticancer therapies and 33% of patients who received curative therapy also reported pain. Over one-third of the patients in the study graded their pain as moderate or severe . The authors concluded that despite the international recommendations from the World Health Organization, pain remained a serious concern for these patients. Deandrea and colleagues confirmed that patients with cancer report undertreatment of pain; in a review of 44 studies, the authors noted that nearly one of two patients with cancer is undertreated for pain .Journal of Clinical Oncology . The prospective, observational study involved 3,123 ambulatory patients who completed a 25-item measure of pain, functional interference, and additional symptoms at the time of initial assessment and 4 to 5 weeks later. In this study, 67% of the patients reported having pain or needing analgesics at the initial assessment; of these patients, 33% were receiving inadequate analgesic prescribing. There was no difference in the adequacy of analgesic therapy noted between the initial and follow-up visits .The most recent study to examine prescribing of pain medications to medical oncology patients with breast, colorectal, lung, or prostate cancer was published in the Increasing awareness and education regarding this potentially devastating symptom continues to be one of the approaches toward improvement of pain management in the cancer patient population; national and international guidelines and recommendations form the foundation for policies and procedures regarding optimal pain management for patients with cancer. Pain relief depends on appropriate management by health-care providers; these individuals must provide adequate care and pain management using the best principles and evidence-based practice information available to them .Advanced practitioners (APs) working in pain and symptom management are helping to forge the way; however, all APs must continue to reinforce these principles and examine their own practices for management of cancer pain. Understanding of the common barriers to adequate pain management is important; comprehensive assessment and understanding of pain syndromes and possible therapies are essential . Better communication between patients and their health-care providers remains a critical part of the plan for optimal pain management .


Propofol is one of common anesthetic drugs used in anesthesia. The most common side effects of propofol are local pain. Pretreatment with lidocaine can reduce propofol injection pain.The aim of the present study was to assess and compare the efficiency of lidocaine 0.4% and 2% in reducing the incidence and severity of propofol injection pain.This was a double blind prospective clinical trial on children 4-8 years old with class ASA I and II candidates who were referred to Dr. Shaikh Hospital in Mashhad for elective surgery. Sample size calculated 50 patients in each groups based on pilot study. 100 children's were randomly divided equally in two groups, who were injected with lidocaine solutions 2% and 0.4% respectively. patient's pain evaluation based on VSD  and NRS  using patient's verbal reaction and behavior namely fretting, hand drag and tearing. The collated data was analyzed.There was nosignificant difference as to the first three variables . The significant difference regarding pain experience in both groups was noteworthy (P > 0.2).Most of the studies compared lidocaine with other drugs or its efficiency at different doses. Our study is different in that we applied a constant dose of lidocaine in various volumes and concentration. This result shows that lidocaine with the same does but lower concentration and higher volume is more effective in preventing propofol injection pain. Using diluted lidocaine with the dosage of 1 mg/kg and a concentration of 0.4% is an effective way to relieve pain caused by propofol injection in children. Propofol is one of the most common anesthetic drugs used for inducting and continuing anesthesia. It is the drug of choice for millions of patients every year because of its rapid onset and short duration of action. Propofol is insoluble in water and is prepared as fat emulsion. The most common side effects of propofol are local pain on injection site as well as blood pressure decline . The incDifferent techniques have been employed to reduce propofol injection pain including diluting, heating and cooling the solution as well as pretreatment with a variety of anesthetics namely lidocaine , metocloIn this study lidocaine was used as the main pretreatment drug to reduce propofol injection pain, with the same dose but at different volume and concentration. The aim of the present study was to assess and compare the efficiency of lidocaine 0.4% and 2% in reducing the incidence and severity of propofol injection pain.This study was a double blind prospective clinical trial on children 4-8 years old with class ASA I and II who were referred to Dr. Shaikh Hospital in Mashhad for elective surgery. Dr Shekh Hospital is special Hospital for children. The inclusion criteria were 4-8 years old children, ASA class I and II, and candidates for elective surgery. The exclusion criteria were contraindication to use propofol or lidocaine, patients with thrombophlebitis, analgesics administration 24 hours prior to the operation and severe mental and neurological disease and neuromuscular disease. We included 100 children (acceptable samples from 138 children) in our study, Then the selected subjects were divided randomly (with regular sampling method) into two equal groups A and B including 50 patients in each groups, who were injected with lidocaine solutions 2% and 0.4% respectively. Dose of lidocaine was 1 mg/kg diluted with normal saline. Patients were also monitored for systolic and diastolic blood pressure changes pulse rate and oxymetry and arythmia using non-invasive techniques such ECG and non-invasive BP measurement prior to anesthesia.All patients received their shots in their left antecubital vein with a tourniquet tied on their upper arm, which was removed 30 seconds following the lidocaine solution injection. We then started to administer propofol 1 mg/kg in 5 – 10 seconds, . Only 1/4 of the entire drug solution was initially administered and the rest were given after patient's pain evaluation based on VSD  and NRS  using patient's verbal reaction and behavior namely fretting, hand drag and tearing.The sampling was conducted in two parts; initially, participants were selected with regular sampling method based on primary pilot study dataand calculated sample sizeand then were randomly divided in two groups. The sample size was calculated by comparing means of difference between groups by confidence interval 95% and study power 80%. We included 100 children (acceptable samples from 138 children) in our study. The collated data with regard to pain intensity and occurrence was analyzed using SPSS 16 Quantitative data was described using mean ± standard deviation whereas P < 0.05 was considered significant.After approval was obtained from the local ethical committee of Mashhad University of Medical Sciences and informed consent was obtained from the parents of patients as local protocol , study was initiated and registered in IRCT(code: IRCT201111208143N1). All of the patients were ensured that their privacy will be kept and their personal information will not disclosed in any circumstance.This is chiefly regarded as a pilot study due to the lack of any similar background research in children.The data pertaining to patients' age, gender and weight in both groups were shown in Propofol, a drug of choice for the induction of anesthesia, can also induce pain on injection site owing to high-fat solubility, thanks to long-chain triglyceride solvents . Pain caOne of the drugs that have been used widely in different trials is lidocaine. Different studies have been performed on lidocaine dosage and way of administration before propofol. Walker et al. In a study published in 2011, administrated lidocaine with tourniquet before propofol in one group, and mixed with propofol in another group. The results were then compared with a group receiving placebo. This study results indicated that propofol injection pain was significantly less in the group who received lidocaine before propofol (P = 0.016) .Khaled also conducted a study on 200 patients in Jordan. He divided patients into 4 groups: the first receiving 4 cc lidocaine 1%, the second group 4 cc (40 mg) paracetamol, the third a mixtures of lidocaine 2% and 100 mg fentanyl, and the forth 4 cc of normal saline. Propofol was administered 60 seconds after pretreatment in all groups. A pain-free injection of 68%, 54%, 70% and 36% were reported respectively. There was not any significant difference between the first and the third group (P > 0.05), but the difference between the forth (placebo) and the other three groups was significant (P > 0.05). There was also a significant difference between the groups receiving lidocaine and the one who received paracetamol (P < 0.05).In conclusion, Khaled reported that lidocaine can relive the propofol injection pain up to 70% .In another study conducted by Beyaz SG in Turkey in 2011, the effect of regular propofol was compared with propofol llipuro with and without lidocaine. 120 children were divided in 4 groups, the first and the second groups received generic propofol, while the other two were given propofol llipuro. Lidocaine was administrated for patients in the second and forth groups. Beyas did not find any significant difference in pain between the first two groups (P > 0.95), but the difference between the third and the forth group (propofol llipuro with and without lidocaine) was significant (P = 0.001) . In SedaGroup 1: 19 cc of propofol ± 1 cc normal salineGroup 2: 1 cc of lidocaine 0.5% (5 mg)Group 3: 1 cc of lidocaine 1% (10 mg)Group 4: 1 cc of lidocaine 2% (20 mg)The four groups comprising 368 females subjects in King SY study  were given the following treatments:A dose-dependent link was found between lidocaine and pain reduction (the last pain was reported in group 4) .Jalota et al. preformed a systemic review on 177 clinical trials including 25260 participants to determine the most effective way for decreasing propofol injection pain. He reported an incidence of 60% for pain on propofol injection in general. He stated that using antecubital vein is the most effective single intervention . Jalota recommended that if the hand vein is chosen as the site of injection, pretreatment with lidocaine in conjunction with venous occlusion, or a combined intervention such as pretreatment with ketamine or lidocaine before injection of a propofol emulsion containing medium and long chain triglycerides is highly recommended .Madenoglu et al. also performed a study in Turkey with the aim of evaluating the efficacy of different doses of lidocaine in the prevention of pain due to propofol injection. 120 patients with ASA class I and II were placed in 4 groups; group 1 received only propofol, group 2 a mixture of propofol and 10 mg lidocaine, group 3, 10 mg of lidocaine 30 seconds before propofol and group 4 lidocaine 1 mg/kg before propofol. They reported that the incidence of pain was significantly lower in groups 2 and 4 compared to groups 1 and 3 . They concluded that a lower dose of lidocaine be more effective, suggesting to mix it with propofol prior to injection . Picard This result shows that lidocaine with the same does but lower concentration and higher volume is more effective in preventing propofol injection pain. In fact, what needs to be the focus of future studies is the lidocaine optimum concentration and volume as only 1 mg/kg lidocaine was used in this study. Madenoglu in his study suggested 10 mg as the effective does for lidocaine. We also need to bear in mind that concentration changes can also affect optimum dosage. What we also need to improve is that the research must include a larger population of subjects, applying more efficient techniques to elicit response to pain as children are often less capable to do so on questioning. Using diluted lidocaine with the dosage of 1 mg/kg and a concentration of 0.4% is an effective way to relieve pain caused by propofol injection in children. Further investigations seem noteworthy owing to the flaws in this study: limited number of participants, poor response elicitation techniques to pain and unblind investigators. A larger blind randomized trial using more efficient elicitation techniques is recommended.


Objective. To examine the efficacy of interdisciplinary rehabilitation for improving function in people with chronic pain. Design. Retrospective Chart Review. Setting. The Pain Rehabilitation Center (PRC) at a medical center. Participants. Individuals admitted to the PRC. Interventions. The PRC operates a 3-week outpatient program that utilizes an interdisciplinary approach to treat people with chronic pain. The main treatment elements include physical therapy, occupational therapy, cognitive behavioral therapy (CBT), and medication management. Physical therapy groups focus on moderate exercise despite symptoms. Occupational therapists teach moderation, time management, and activity modification. CBT groups, led by a pain psychologist, address the psychosocial comorbidities of chronic pain. Medical staff oversee the tapering of opiate analgesics and other symptom targeted treatments. This integrated approach is indicated when conventional treatments have been ineffective. Outcome Measures. The objective outcome was the 6-minute walk test (6 mWT) distance. The subjective outcomes were performance (COPM-PER) and satisfaction (COPM-SAT) as measured by the Canadian Occupational Performance Measure (COPM). Results. Average 6 mWT distances improved by 39% from 375 m to 523 m. Average COPM-PER scores increased from 3.4 to 7.5. Average COPM-SAT scores increased from 2.4 to 7.5. Conclusions. Comprehensive interdisciplinary outpatient rehabilitation can significantly improve function in people with chronic pain.  Chronic pain is a complex clinical entity that can affect every aspect of a person's life. The physical consequences of chronic pain include deconditioning, loss of mobility, loss of independence, increased medical comorbidities, and long-term reliance on pain medications. From a psychosocial perspective, these people often experience high levels of emotional distress, insomnia, and impaired social and occupational functioning .Comprehensive, intensive, interdisciplinary, pain rehabilitation programs are safe and effective in treating people with chronic pain –5. A groMultiple studies have reported positive functional outcomes based on patient self-assessment –8, but fOur team retrospectively analyzed the objective and subjective functional outcomes of our comprehensive outpatient pain rehabilitation program to assess its efficacy and to guide efforts towards future prospective research.The authors retrospectively analyzed the 6 mWT and COPM data of the first 150 patients enrolled in the Comprehensive Pain Rehabilitation Center (PRC) program from October 2011 to August 2012. A physician medically cleared each PRC patient to participate in the 3-week rehabilitation program. As part of the regular physical therapy and occupational therapy evaluations and treatment plans, data on the 6 mWT and the COPM were collected and recorded at both the admission and dismissal appointments. Patients voiced an interest in improving daily function and a willingness to taper and cease all pain medications and pain behaviors. Patients with acute pain or illness and those not willing to participate fully in all the components of the treatment program were not admitted to the PRC and thus excluded from this study.The physical therapy component of the interdisciplinary treatment approach focuses on general reconditioning with graded exposure to activity, gradual reduction of fear-avoidance behaviors, and incremental elimination of other pain behaviors. Each patient attends three daily exercise sessions. Morning stretch group is the first session of the day and incorporates 15–20 minutes of whole-body active range of motion, gentle dynamic stretching, moderate static stretching, balance, and coordination training. Patients are encouraged to perform these exercises on the weekend and are instructed in appropriate individual modifications as needed. Cardio and strength groups are also performed, Monday through Friday. Patients are specifically instructed not to perform these exercises on the weekend to minimize maladaptive exercise techniques. During cardio group, each patient's goal is to complete 20–30 minutes of moderate conditioning activities within an age determined target heart rate zone and to cool down from that session with an additional 5–10 minutes of static stretching. During strength group, each patient uses free weights, resistance bands, or body weight resistance to complete a whole-body strengthening and stability circuit. Patients generally finish this session in 45–60 minutes.The occupational therapy component of the interdisciplinary treatment approach focuses on moderation and balance of daily activity with modification as needed to increase functional independence and participation in life roles. Group lecture topics include bathroom safety, body mechanics, cleaning, cognitive strategies, driving, fall prevention, garage, garbage, home safety, kitchen, laundry, making the bed, moderation, modification, self-care, shopping, time management, values, vocation, workspace ergonomics, and yardwork. Each Friday, the occupational therapists (OTs) lead a time management session for weekend planning to help the patients appropriately moderate their schedule and balance activity during their time away from the structure of the program. The OTs meet with each patient individually on several occasions throughout the program. Midway through the program, on day 8, an OT meets individually with each patient to begin planning his or her days immediately after the program. There are also three individual biofeedback sessions during which patients learn diaphragmatic breathing and muscle relaxation and how to utilize these strategies during daily activity and functional mobility.A pain psychologist leads up to three group therapy sessions each day. Discussion topics include anger, anxiety, assertiveness, behavior change, central sensitization syndrome, cognitive behavioral therapy, cognitive coping skills, chronic pain cycles, depression, difficult day planning, distraction, drug interventions, fear, forgiveness, goal setting, grief, maintaining lifestyle changes, pain behaviors, PRC programs concepts, perfectionism, personal responsibility, problems solving, relationships, relaxation, self-esteem, sleep, stress, and withdrawal. There are also weekly question and answer sessions for the group members with no scheduled topic and weekly sessions for family and friends to learn about PRC program and ask questions. Each of the discussion sessions is an hour long and group members are encouraged to participate and ask questions as they arise. When there are fewer than three of these lecture sessions in a day, there are work groups for distraction and difficult day planning, nutrition, posture, and PRC program tools that are led by PRC staff and consultants.Throughout the three-week program, nurses serve as individualized and highly specialized patient care coordinators. They take the lead role in medication management and tapering (under the direction of a physician and physician assistant). With patient authorization, nurses in the program also continually communicate with primary and specialty care providers outside of the PRC team to assist with continuity of care into the future.The 6 mWT is a submaximal, performance-based measure of functional capacity. It was first defined by Dr. Balke in 1963  and has For each patient, one of the four physical therapists (PTs) performed the 6 mWT. A 30.48 m (100 foot), demarcated, up-and-back walkway was used along with a stopwatch to keep time. Instructions given before the test began were to walk up and down the hallway safely, covering as much distance as possible in 6 minutes, without running. Patients were further instructed to only take rest breaks if needed, but the time would continue to count down. During the test, time updates were provided every 30–60 seconds without encouragement.The COPM is a quality-of-life measure designed to capture limitations in relation to activities of daily living. The patients rate their performance and satisfaction in the areas of self-care, productivity, and leisure. The COPM has been validated in diverse patient populations  includinThe COPM was administered in a semistructured interview format by 1 of 2 OTs during the occupational therapy evaluation. The patient was asked to provide a self-report of occupational performance limitations and to rate each problem on level of importance . The patient was then asked to rate their performance for the top five most important items . Lastly, they were asked to rate their current satisfaction  with that performance level.Note that the OT did not reveal to the patient their initial scoring until after the discharge scoring was complete to help reduce any scoring bias.All statistical analyses were performed using JMP computer program , version 10.0.0. The results were considered statistically significant at the 0.05 level. Confidence level was set at 95%. The data were analyzed using ANOVA test assuming equal variance. This was done to minimize error variance and more accurately detect pre- to posttreatment differences.p < 0.0001). Over three-quarters (78%) of the admitted patients were employed before the initial onset of chronic pain, yet only 21% of them worked at the time of admission.These PRC patients had a primary diagnosis of central sensitization syndrome with mixed pain sources reported . Out of the 150 patient charts that were retrospectively analyzed, 132 patients successfully finished the program, 17 patients quit before finishing the program, and one patient's 6 mWT data was not documented. The 17 patients that left the program early had similar demographics and pain conditions as the rest of the patients. The gender distribution of patients was 114 females (76%) and 36 males (24%). The average age was 51 years, with a range from 19 to 85 years. Demographics of admitted patients were as follows: 89% white, 5% black, and 1% Asian, and the remaining 5% declared themselves as others . The edut-test analysis, with p value less than 0.0001.At admission, patients walked an average of 375 m  during the 6 mWT . The samAt admission, patients rated themselves an average of 3.4 and 2.4 out of 10 for the COPM performance (COPM-PER-pre) and satisfaction (COMP-SAT-pre) scores, respectively . At dismIn many cases of chronic pain, significant pain reduction is not possible, whereas increasing function and quality of life is a reasonable and achievable goal. Interdisciplinary pain rehabilitation programs have been successful in the rehabilitation of people with chronic pain. We use the 6 mWT and COPM to assess functional capacity and occupational performance in all of our patients at admission and dismissal. We retrospectively assessed the progress and satisfaction of the first 150 patients enrolled in our PRC program.The distance covered in the 6 mWT correlates with functional capacity and independence with activities of daily living. Walking speed has been referred to as the sixth vital sign . Poor waChanges in COPM scores from assessment to reassessment tend to be meaningful  and a chThese findings add to the well-established pain rehabilitation literature. The PRC program positively impacts functioning for a broad range of people. By using the 6 mWT, we have objectively demonstrated that improvements are clinically meaningful, as patients' progress from needing interventions to reduce fall risk to being independent in activities of daily livings.The main limitation of this retrospective study design is the lack of an appropriate control group; however, each patient's pre-PRC program data is a representation of their own status having tried many of the conventional treatment options. Future studies would be beneficial to analyze these effects prospectively and a longitudinal follow-up study would be able to investigate if these positive results persist over time.