The Michigan Hand Outcomes Questionnaire—MHQ—is a well-known self-assessment questionnaire, where patients’ own perception in terms of recovery, pain and the ability to return to activities of daily living is assessed. The purpose of the study was to translate and culturally adapt the Michigan Hand Outcomes Questionnaire to Swedish and to test the validity and reliability in patients with surgically treated distal radius fractures.The cross-cultural adaptation and the translation process were conducted according to predefined guidelines. Seventy-eight patients with surgically treated distal radius fractures completed the translated version of the questionnaire on their six-week follow-up visit.The translation and cross-cultural adaptation process revealed no major linguistic or cultural issues. The internal consistency of the MHQ-Swe ranged from 0.77 to 0.94 at test 1 and from 0.81 to 0.96 at test 2 for all subscales, which indicates good internal consistency in the subscales. The hand function subscale revealed the lowest results and work performance the highest. The ICCs showed excellent test-retest reliability, ranging from 0.77 to 0.90 on all MHQ subscales and 0.92 on total score. The highest results for the ICC were seen in the satisfaction subscale (ICC = 0.90), while the lowest were seen in the aesthetic subscale (ICC = 0.77). The correlation analysis between the MHQ-Swe, PRWE and VAS showed a generally moderate to high correlation for all the subscales.The Swedish version of the MHQ, the MHQ-Swe, showed good validity and reliability and it is therefore an appropriate and relevant questionnaire for use in patients with surgically treated distal radius fractures.208491, registered December 9, 2015.FoU i VGR, Projectnumber:  A distal radius fracture (DRF) is one of the most common skeletal injuries . The incThe use of PROMs after a DRF provides important information in terms of the patient’s subjective perception of hand function, activity level and final outcome after surgery. When compared with traditional measurements evaluating outcomes, such as ROM or the presence of complications, PROMs add another dimension to the outcomes and the treatment efficiency and patient well-being . PROMs cThe Michigan Hand Outcomes Questionnaire, the MHQ , is regaWhen translating a questionnaire, it is important not only to translate it but also to adapt the questionnaire cross-culturally and evaluate its validity and reliability in different patient groups. Activities of daily living (ADL) are closely related to the use and function of the hand and wrist. Sociocultural and linguistic differences in the activities of daily living could affect the validity of the translated questionnaire and it is crucial to have a linguistically and culturally well-adapted process . The purPermission to use and translate the MHQ  was obtaThe Michigan Hand Outcomes Questionnaire—MHQ—was developed in 1998 by Chung et al., with the goal of creating a questionnaire which could be used to measure outcomes for patients with hand injuries [The raw score for each subscale is the sum of the responses for each scale item, which is converted to a score ranging from 0 to 100. The total scores in the subscales range from 0 to 100, with a higher score indicating a better result, apart from pain. On the pain scale, high scores indicate more pain. Depending on which hand is affected, the right- or left-hand score on each subscale is selected to calculate the total score on the subscale. If both hands are affected , the right- and left-hand scores are averaged. A total score is calculated by adding up the total scores on the subscales after reversing the pain scale score and then dividing by 6 .The Patient Rated Wrist Evaluation (PRWE) was developed in 1996 by MacDermid , 19. ThePain was measured on a VAS , with twThe translation and cross-cultural adaptation were based on pre-defined guidelines formulated by Beaton et al. . Two proThe preliminary version of the questionnaire, the MHQ-Swe, was tested in a clinical setting in 40 patients. The final version was completed and every part of the translation and cross-cultural adaptation process was presented to the developers of the questionnaire. The final version of the questionnaire was then tested for psychometric properties.The patients were recruited consecutively at an orthopaedic hand therapy unit. Patients, aged 18 years and over, with a distal radius fracture, all treated surgically using a volar plate, who spoke and understood Swedish in speech and writing, were asked to participate in the study in connection with a return visit to an occupational therapist (OT) 6 weeks post-surgery. All the participants gave their written, informed consent to participate in the study. Patients with other injuries/diseases in the hand/arm/shoulder that could have affected their activity performance or had diagnosed dementia or some other cognitive impairment were excluded.At the visit, the OT collected demographic and clinical data, which included aspects of age, gender, hand dominance, information regarding the injury and the VAS, MHQ-Swe and PRWE.Seventy-eight patients participated in phase 2. The demographics of the 78 participants in phase 2 are presented in Table Reliability is a consistency measurement and can be described in terms of reproducibility and internal consistency. The internal consistency assesses the consistency of the respondent’s answers across items within a questionnaire and is important when it comes to evaluating the correlation between the questions on each subscale.A test of reproducibility was performed through a test-retest, where patients filled in the MHQ-Swe twice, once at their 6-week postoperative visit, and once at home 5 to 7 days after the visit. The last questionnaire was then returned by mail. At the 6-week postoperative visit, the patients also completed the PRWE and estimated their pain on a VAS in order to test the validity of the questionnaire. The construct validity was assessed by comparing the subscales of the MHQ-Swe with the Swedish version of the Patient Rated Wrist Evaluation (PRWE)  and the The collected data were analysed with SPSS software (version 27).Descriptive statistics were used to describe the participants’ characteristics.The calculations in the current study were, where applicable , performed on the injured hand and not on the right and left hand.Internal consistency was assessed using Cronbach’s alpha. A higher coefficient (range 0–1) indicates a more consistent scale. A threshold value of 0.80 was considered acceptable.Test-retest was assessed using an intraclass correlation coefficient (ICC). The classification suggested by Cicchetti et al.  as poor The association between the domains in the instruments was calculated using Spearman’s rank correlation. In interpreting the correlation strength, the limits of r = 0 for no correlation, r = 0.1–0.3 for weak correlation, r = 0.4–0.6 for moderate correlation, r = 0.7–0.9 for strong correlation and r = 1 for perfect correlation were used .The translation and cross-cultural adaptation process revealed no major linguistic or cultural issues. Some minor discrepancies regarding cultural differences were encountered. For example, the question relating to “Turn a door knob” was altered to the Swedish wording for “att skruva i en glödlampa” (screw in a light bulb) after the translation process and expert group, as door handles are used instead of knobs in Sweden. Moreover, the question about “Carry a grocery bag” was altered, because this activity is not two handed in Sweden.Forty patients  with surgically treated distal radius fractures participated in phase one, testing of the pre-final version of the questionnaire, and they were asked whether any question appeared to be unclear, if something was missing or needed to be added. Most of the patients had no comments or questions about the questionnaire, but some of the patients addressed some issues. Mainly, some of the older women argued that it was difficult to answer the question about “your normal work” due to retirement. This question was altered to suit patients who were retired as well.The average scores for the instruments are presented in Table The internal consistency of the MHQ-Swe, estimated by the internal consistency coefficient Cronbach’s alpha, ranged from 0.77 to 0.94 on test 1 (T1) and from 0.81 to 0.96 on test 2 (T2) for all subscales, which indicates a good internal consistency on the subscales Table . The hanThe ICCs showed excellent test-retest reliability, ranging from 0.77 to 0.90 on all MHQ subscales, and 0.92 on total score. The results of the intraclass correlation for the test-retest are shown in Table The correlation analysis between the MHQ-Swe, PRWE and VAS generally revealed a moderate to high correlation for all the subscales Table . The MHQThe purpose of the study was to translate and culturally adapt the MHQ to Swedish and to test the validity and reliability in Swedish patients with surgically treated distal radius fractures. No major issues were revealed in the process of translation and cultural adaptation and the MHQ-Swe showed good validity and reliability in patients with surgically treated distal radius fractures.The internal consistency of the subscales was high 0.77–0.96) and, despite being slightly lower than the original MHQ, it is still reflected (0.86–0.97) [6 and, deTest-retest reliability was tested with the ICC. The ICC was excellent on all subscales, slightly lower, but still comparable to the original questionnaire  , 15, 27.A distal radius fracture is a temporary and hopefully transient injury, but it can be expected to affect a person’s involvement in daily activities for a limited time, and can therefore be called an occupational disruption. An occupational disruption is described by Whiteford  as “a teThe hands and their function are complex and very important for human beings, which makes a multifaceted evaluation questionnaire important. In this way, the MHQ has several favourable components. It is valuable to employ a questionnaire that has a holistic approach towards assessing variables related to hand injuries. The questionnaire includes aesthetics, something that is lacking in most questionnaires, and this could be important for many patients. The questionnaire also takes patient satisfaction with different aspects on the hand and its function into account, which is highly relevant. The questionnaire takes both hands into account, which is valuable, first and foremost for bilateral injuries and diseases, but this could also be somewhat confusing for the patient group in the study. Several patients did not fill in the function of the non-injured hand, which resulted in missing data, but, as we chose only to analyse the injured hand, this was not regarded as a major issue.The MHQ scoring algorithm is somewhat complicated, as a few of the questions on the subscales, as well as an entire subscale (IV), have to be reversed to obtain a total score using the questionnaire. The reversed questions also confused some of the patients. For example, in terms of the aesthetic subscale (V), some patients did not read the questions in full and answered the opposite of what they should have answered. The first question on the subscale is the reverse of the other three questions and this may have resulted in some of the participants misunderstanding it and giving contradictory answers. One suggestion for improving the user friendliness would be to create an electronical version, with an automatic scoring algorithm, perhaps one for unilateral injuries and one for bilateral.In terms of phase 1, where a group of patients completed the form and then answered questions about the questionnaire, it is possible to discuss whether the answers and feedback would have been different if we had conducted interviews instead of giving the respondents a form to fill in. This could be a limitation to the design and cultural adaptation of the questionnaire. In retrospect, we could also have added a question about the patient’s perception of the time consumption of the questionnaire and a question about its relevance to the current injury. The fact that we only calculated the results for one hand in the study is also a limitation.The MHQ-Swe is an appropriate and relevant PRO questionnaire, with good validity and reliability, for use in patients with surgically treated distal radius fractures.


A prominent feature of ankle sprains is their variable clinical course. The difficulty of providing a reliable early prognosis may be responsible for the substantial rate of poor outcomes after an ankle sprain. The aim of the present study was to evaluate the prognostic value of objective clinical measures, pain, and functional scores for ankle sprain recovery. Fifty-two participants suffering from lateral ankle sprain were included. Sprain status was assessed four weeks following injury and included evaluations of ankle range of motion, strength, function, and pain. Seven months following injury, a second assessment classified the patients into recovered and non-recovered groups using ankle ability measures. Following a predictor pre-selection procedure, logistic regressions evaluated the association between the four-week predictors and the seven-month recovery status. Twenty-seven participants (52%) fully recovered and 25 did not (48%). The results of the logistic regressions showed that walking pain was negatively associated with the probability of recovering at seven months . Pain four weeks after ankle sprain had relevant predictive value for long-term recovery. Special attention should be paid to patients reporting persistent pain while walking four weeks following sprain to reduce the risk of chronicity.  Lower-extremity joint injury is among the most common consequences of accidents occurring in recreational and athletic activities . A largeFollowing an initial assessment , acute treatment for ankle sprains entails anti-edema measures ), anti-inflammatory medication, and weight-bearing support by means of a brace. Severe sprains may require rigid immobilization (ten days), followed by a transition to semi-rigid external constraints ,9. SurgiHealing times and capacities to achieve full recovery vary among patients recovering from ankle sprain. Some of these patients will return to their daily living activities without limitations within a few days, without having to take part in physical therapy. Others will develop chronic ankle instability (CAI) and chronic pain and will endure sprain sequelae over a period of years after the injury despite intensive rehabilitation. Roughly, one out of every five members of the public who incur an ankle sprain will report chronic problems ,14. A syOne reason for the non-negligible rate of poor outcomes following ankle sprain is the difficulty inherent in providing a reliable prognosis. For example, structural lesions found by radiological investigation  are not related to the persistent complaints of patients . A variaWhat kinds of clinical observation may be helpful in characterizing patients at risk of developing complications after ankle sprain? A recent systematic review of nine articles summarized the prognostic factors of recovery following acute lateral ankle sprain . With reThe present study is part of an effort to improve the management of patients suffering from lateral ankle sprain. In this context, it is essential to characterize factors that may be associated with an unfavorable sprain evolution to detect patients most at risk of complications. Therefore, the objective of this study was to evaluate the prognostic value of objective clinical measures, self-reported pain, and functional scores acquired four weeks following injury to predict long-term (seven-month) recovery.The study is a secondary longitudinal analysis of the results of a randomized controlled trial (RCT) . ClinicaThe motivation for this study was to harness the data of the RCT to better analyze the outcome of the patients. Given that RCT imposed well-defined therapies to participants over six weeks, we found it interesting to assess the long-term recovery and its association with early clinical measures. The idea was to find relevant markers for chronicity.Between April 2010 and July 2014, 90 patients with acute lateral ankle sprains were recruited from the emergency department of the University Hospital of Geneva in Switzerland. The inclusion criteria covered adults aged between 18 and 65 years with grade I or II ankle sprains . PatientThe included patients were discharged from the emergency department with semi-rigid Aircast ankle braces and standard painkillers. The physician provided standard instructions regarding the PRICE protocol and recommended only performing pain-free movements for four weeks . PatientTM, or no therapy [Four weeks after injury, the patients attended appointments with an experienced physical therapist who took clinical measurements suspected to serve as predictors of recovery. The physician also recorded the patients’ self-reported pain and self-reported physical functioning (see below for further details concerning the measured predictors). The decision to assess the patients’ conditions at this time was guided by previous results, which showed that clinical assessment administered at four weeks could serve as predictors of recovery . Further therapy . ConventSelf-reported physical function of the ankle was reassessed seven months after injury.The main outcome (dependent variable) was whether the study participants were healed from their ankle sprain seven months after the injury. Following the recommendation of Wikstrom , patientEdema: To assess edema (joint swelling), we measured circumference (tape measure) of the ankle at the level of both malleoli and foot circumference, midway between the lateral malleolus and the base of the second metatarsal [tatarsal . These mJoint mobility: Passive ankle ROM was measured with a manual goniometer , Italy). Both plantar and dorsal flexion were tested. Dorsal flexion was measured in both an extended knee position and a 90° flexed knee position [position . These mMuscle strength: The maximum isometric muscle strength of the ankle’s plantar and dorsal flexor, invertor, and evertor was measured with a handheld dynamometer . The foot was placed in a neutral position, and the examiner held the dynamometer stationary while the patient exerted maximal force against it. The dynamometer was positioned as recommended by Spink et al. [k et al. . Each meSelf-reported pain: Pain was evaluated by means of a visual analogue scale (VAS) both at rest and while walking [ walking . Each paSelf-reported physical function of the ankle: Ankle function was evaluated with the FAAM questionnaire, which is a valid and reliable self-report questionnaire for patients with foot and ankle disorders [isorders ,26. ThisWe assessed the different predictors of recovery as follows (further information about the measurement methods can be found in ): Edema:Overall, 13 predictors were used as independent continuous variables. Body mass index (BMI), and sex were also included as covariates. The RCT results showed that the type of rehabilitation had no influence on the patients’ recovery statuses. For the sake of completeness, we still included rehabilitation type in the analysis as a three-level categorical variable.Party (v. 1.2-2) R (v. 3.3.3) package and the cforest function [varimpAUC) [Owing to the high number of potential predictors of ankle sprain recovery, we preselected the most relevant predictors through a random forest (RF) approach . The aimfunction ,29,30 torimpAUC) ,32,33. TThe most important predictors, preselected via RF, were then applied as independent variables in logistic regressions, with recovery status as the dependent variable. Both simple and multivariate regressions were evaluated, including interactions. Model selection was carried out using the Bayesian information criterion (BIC), which penalizes model complexity. Discriminative performance was estimated by means of a receiver operating characteristic (ROC) curve and the area under the curve (AUC) with 95% confidence intervals (CI) computed by bootstrapping. The odds ratio of the best model was computed to evaluate effect size. The significance level (type I error rate) was set to 0.05.Among the 90 patients that participated in this RCT, 52 completed the seven-month follow up. Reasons for dropping out included: geographical reasons (n = 4), pregnancy (n = 1), surgery unrelated to the ankle sprain (n = 3), new ankle sprain (n = 2), disinterested in continuing (n = 1), holidays (n = 1), sickness due to other disease (n = 2), the time-consuming nature of the follow-up (n = 4), and unknown reasons (n = 20).Among the 52 participants who attended the seven-month follow-up, 27 patients recovered (52%) and 25 patients did not (48%). The means and standard deviations of the demographic factors are presented in Due to three missing pieces of data, only 49 participants were included in the RF analysis. The RF analysis correctly classified 62% of the participants. The kappa coefficient was 0.24, corresponding to a poor agreement . The VIMGiven that two predictors were considered important according to the VIM analysis, four logistic models were tested on the full dataset . The univariate model, including only pain while walking, exhibited the lowest BIC and an AUC of 0.73 . MultivaThe best model indicated that pain while walking was negatively associated with the probability of recovery . In other words, the odds of recovery seven months after the sprain decreased by 29% for each additional point on the pain scale assessed four weeks after the injury.This study aimed to assess the prognostic value of objective clinical measures , self-reported pain, and functional scores assessed four weeks after an ankle sprain to predict recovery at seven months. 2 = 0.27, p = 0.60). The independence of recovery status from the severity of the initial sprain has been attested by a previous systematic review [First, we observed that 48% of the study participants did not fully recover from their ankle sprains seven months after their accidents. Comparable rates of poor long-term recovery have been reported in several studies ,34,35. Ic review . The results of the present study suggested that perceived pain during walking is associated with long-term recovery. This finding is in line with those of previous studies, which have evidenced an association between limitations in weight-bearing activities and disability duration , as wellAnother study has suggested that recovery can be predicted based on walking ability immediately after the injury . HoweverAt first sight, patient’s pain levels while walking were low. On average, participants who fully recovered scored 1.6 on the 0–10 VAS scale, while participants who did not fully recover scored 3.3 . HoweverIn contrast with self-reported pain, functional capacity assessed via the FAAM questionnaire did not reveal itself as a predictor of recovery. The results of three previous studies contrast with this finding. Firstly, Cross et al. observed that the results of the short form-36 physical functioning scale (SF36PF) correlated with the number of days to return to sport . SecondlFour weeks after their sprain, the study’s participants still experienced substantial reduction in strengths and ranges of motion, as well as residual edema . HoweverThe physio-pathological mechanisms of ankle-sprain recovery that lead to either rapid healing or CAI are largely unknown. Recent studies have suggested that successive cascades of sensorimotor reorganization may occur in this process . PatientA strong point of the present study is its external validity. The present study sample included participants representing the general population. All the participants were included in a monocentric RCT, and therefore received uniform care. In addition, all the examined predictors were easily measurable and validated variables, and a clear definition was used for the seven-month recovery status. Finally, we used statistical methods that minimized the risks of overfitting.Our study had some limitations. First, the sample size was dependent on the size of the parent RCT. Given the large inter-individual variability of the sample , and theIn summary, the present study highlighted that (1) nearly half of the patients who underwent lateral ankle sprain had not fully recovered seven months after their sprains, and (2) pain while walking, assessed four weeks after lateral ankle sprain, may help in predicting recovery at seven months. These findings confirm the substantial heterogeneity of the clinical course of ankle sprain. These findings also highlight the importance of the assessment of pain while walking in detecting patients at risk of poor long-term prognosis. Assessing patients after the acute phase of ankle sprain recovery may help in selecting ideal rehabilitation treatments. Particular attention should be paid to patients with persistent pain in order to reduce the risk of chronicity.


Bone mineral density (BMD), derived opportunistically from computed tomography (CT), did not significantly differ between the groups (p = 0.66), but cages were more frequently implanted in patients of the S2A group (p = 0.04). SL of sacral or iliac screws was more common in patients of the S2A and I groups compared with the S2AI group . SIJ pain was more often improved in the S2AI group not only after 3 months but also at maximum FU . Even in shorter or mid-length lumbar or thoracolumbar constructs, S2AI might be considered superior to S2A and I instrumentation due to showing lower incidences of caudal SL and SIJ pain.Lumbosacral instrumentation continues to be challenging due to complex biomechanical force distributions and poor sacral bone quality. Various techniques have therefore been established. The aim of this study was to investigate the outcome of patients treated with S2-alar-iliac (S2AI), S2-alar (S2A), and iliac (I) instrumentation as the most caudal level. Sixty patients underwent one of the 3 techniques between January 2012 and June 2017 . Mean age was 70.4 ± 8.5 years. Screw loosening (SL) and sacroiliac joint (SIJ) pain were evaluated during the course at 3-month and maximum follow-up (FU). All patients completed 3-month FU, the mean FU period was 2.5 ± 1.5 years ( Instrumentation of the lumbosacral spine continues to be a challenging area in spine surgery, particularly due to complex local anatomy, unique biomechanical force distributions, and comparatively poor sacral bone quality. Various concepts for construct improvement have therefore been developed. However, there is a high rate of screw loosening (SL), instrumentation failure, pseudarthrosis, and sacroiliac joint (SIJ) pain up to 83%) –3.% –3.3].The Galveston technique and iliac screws were the first approaches trying to improve caudal instrumentation by extending the construct down to the pelvis , 5. HoweThe search for alternative techniques to this point ended in the description and clinical establishment of the S2-alar-iliac (S2AI) screw trajectory . By crosWe therefore hypothesize that instrumentations including S2AI screws are less prone to SL and SIJ pain compared with other established techniques. Thus, the aim of this study was to investigate differences in outcome between patients treated with S2AI, S2-alar (S2A), and iliac (I) instrumentation as the most caudal level.We reviewed all medical records and specifically checked the pre- and postoperative examinations including imaging studies, as well as postoperative follow-up (FU). The study enrolled 60 consecutive patients  who underwent instrumentation by one of the 3 techniques between January 2012 and June 2017 as revision surgery after initial instrumentation . Outcome  was compared between the 3 groups considering preoperative, 3-month FU, and maximum FU examinations. Pain was routinely evaluated over the whole observation period during treatment and FU using a 10-point visual analogue scale.Bone mineral density (BMD) was opportunistically assessed in preoperative imaging by computed tomography (CT) . The 3 gThis study was approved by our local ethics committee (registration number: 159/16S) and was conducted in accordance with the Declaration of Helsinki. Informed consent was not required due to the retrospective character of the study and the conditions of our local ethics committee.https://www.r-project.org/). p values < 0.05 were considered statistically significant.All analyses were performed with the statistical software R , median and ranges, or absolute or relative numbers were calculated. Depending on data distribution, analyses of variance (ANOVA), Kruskal-Wallis tests, or Chi-squared tests were used to assess differences in the analyzed parameters between the 3 groups.The proportions and absolute numbers of patients with SIJ pain according to preoperative assessment, as well as at 3-month and maximum FU, were calculated stratified by group, respectively. Furthermore, proportions and absolute numbers of patients with improvement, deterioration, and unchanged status in SIJ pain at maximum FU compared with the preoperative status were calculated. Differences in these proportions between the 3 groups were assessed using Chi-squared or Fisher’s exact tests.t tests, Mann-Whitney U tests, or Chi-squared tests. Improvement at maximum FU compared with the preoperative status was considered. The Benjamini-Hochberg procedure was used for correction of multiple testing regarding these prediction analyses, assuming a false discovery rate of 25%.Potential predictors for improvement in SIJ pain were assessed, again stratified by group. Specifically, mean and SD, median and ranges, or absolute or relative numbers were calculated in patients with improvement and in patients with deterioration or unchanged status regarding SIJ pain. Associations with this status were tested using Participants’ mean age was 70.4 ± 8.5 years. The general demographics of all 3 groups are outlined in Table p = 0.38). A median of 4.5 to 5 segments  and 3 segments (I) was operated on (p = 0.26), extending to S2 or the os ilium, respectively. BMD as assessed opportunistically by CT did not significantly differ between the groups (p = 0.66). Cages were more frequently implanted in patients of the S2A group (p = 0.04).All patients completed 3-month FU; maximum FU times were 2.3 ± 0.9 (S2AI), 3.0 ± 1.7 (S2A), and 2.4 ± 1.6 (I) years (p = 0.03).SL of sacral or iliac screws was more common in patients of the S2A and I groups when compared with the S2AI group  leakage due to surgery was observed in 3 patients (16.7%), whereas hematoma occurred in 1 patient (5.6%). Furthermore, 3 patients (15.0%) of the S2A group showed CSF leakage, and 2 (10.0%) showed hematoma, whereas another 2 patients (10.0%) showed screw dislocation with cement leakage in 1 case. Among patients of the I group, 1 patient (4.5%) showed screw dislocation.Regarding postoperative medical complications, urinary tract infection was most common , followed by deep vein thrombosis , partially with related pulmonary artery embolism . Two patients of the S2A group developed pneumonia, 1 patient of the S2AI group had a postoperative non-ST-elevation myocardial infarction, and 1 patient of the I group had postoperative endocarditis.Our main findings were that S2AI showed superiority compared with S2A and I techniques in terms of reduced caudal SL and a lower rate of SIJ pain. Additionally, none of the differences between groups significantly promoted these effects.Considering the results, any of the 3 techniques is better than using S1 instrumentation as the caudal part at all . ClinicaAlthough literature reports a considerably high rate of lumbosacral non-fusion of up to 83%, the rate was considerably lower in our series, despite the analyzed groups and despite all cases being revision cases , 16–18. The current best level of evidence originates from a meta-analysis of 5 retrospective studies reporting a significantly lower rate of revision surgery, wound infection, and screw-related pain for S2AI versus iliac screws . HoweverIn previous studies, such as the already mentioned meta-analysis, there was a difference in indications for spinopelvic instrumentation and in the rate of patients receiving anterior cage support , which wIn conclusion, even in shorter or mid-length lumbar or thoracolumbar constructs, S2AI might be considered superior to S2A and I instrumentation due to lower incidences of caudal SL and SIJ pain. However, the superiority not only is in the outcome, but the surgical technique also provides some advantages by allowing for small incisions due to diverging trajectories, less dissection, and in-line rod bending without the need for additional connectors. Because the trajectory is more demanding, thus potentially causing more anterior complications, we recommend spinal navigation to ease the approach, as done in all cases of this study. Although our data might be partially biased, the results and clinical experience are clear. We therefore advocate for the S2AI technique as the caudal end of longer instrumentations. Future prospective studies enrolling larger series should be conducted to confirm these initial results.


The benefits of providing static stretching exercise targeting the hips in patients with non-specific Low Back Pain (NSLBP) are not well established. The objective of the study was to verify the effects of static stretching on function, pain and range of motion on patients with non-specific Low Back Pain (NSLBP).Thirty females with NSLBP were randomly assigned to two control (n = 15) and experimental (n = 15) groups. The experimental group received 3 stretch practice sessions per week for a period of 8 weeks. The Oswestry low back pain Disability Questionnaire (ODI), visual analog scale (VAS), and passive hip range of motion (PROM) were employed before and after the intervention.The results of mixed model analysis of variance indicate that the group × time interactions was not significant (p > 0.05) for all measurement outcomes. However, there was a main effect for Time . Such that the ODI, VAS, PROM-R, and PROM-L were showed significant differences before and after the intervention in the experimental group.The results demonstrated a significant difference in PROM, pain, and disability after 8 weeks of stretching exercises in participants with NSLBP and limited hip extension. Therefore, it would be reasonable to infer that NSLBP might be partly related to hip flexors tightness. Nonspecific low back pain (NSLBP) is a common condition, although the mechanisms of its occurrence are still not totally clear. Most people experience NSLBP more than once in their lifetime , 2. ReceHip range of motion (ROM) is one of the vital movements for the natural load distribution mechanism in the hip and the function and loading of the spine and hip , 3. AlsoTo date, there is no evidence regarding the effect of static stretching exercises for hip flexor muscles on hip ROM, pain, and disability of patients with NSLBP. In this regard, restricted hip flexor mobility has been clinically defined as the inability of the individual to achieve full hip extension during the modified Thomas test position . In rehaTherefore, it may be important to consider hip mobility restrictions and their potential impact on pain and disability in patients with NSLBP. The purpose of the present study was to examine the effect of stretching exercises on hip passive ROM (PROM), Pain, and disability in patients with NSLBP. The authors hypothesized that significant differences in hip PROM, pain, and disability would result between pre and post stretching intervention protocols in the participants with NSLBP.According to G*Power software v 3.1 , with a power of 0.8, effects size of 0.29 and an alpha level of 0.05, 26 females with NSLBP were required in this study. Accounting for a dropout rate/loss to follow up to 15%, a total of 30 female participants were required in this study. Afterward, the participants were randomly allocated to the experimental and control groups in a 1:1 ratio : The Disability index of NSLBP was evaluated using the ODI. The modified ODI is a 10 question condition-specific measurement of pain and disability for individuals with NSLBP. Each question is scored from 0 to 5 and summed for determination of total score, which is multiplied by 2 and expressed as a percentage .VAS measurement: The pain level was evaluated using a visual analog scale . Zero indicated no pain and 10 cm indicate the worst pain level. The VAS score of 1.7 cm is reported as a minimal clinically important difference .Hip PROM measurement: To measure the angle of the hip extension PROM, the universal goniometer was used while the participants were positioned supine and a modified Thomas test was performed. The modified Thomas test, typically used to measure the flexibility of the hip flexors to measure hip extension PROM, has been found to possess good reliability , 19. TheDescriptive analysis (mean and standard deviation) was performed on all the variables. The Shapiro–Wilk test was used to ascertain whether the data showed normal distribution. Therefore, a 2 × 2 mixed model analysis of variance was conducted. The between-subjects factor was group  and the within-subject factor was the time . The Cohen d coefficient was used to determine effect size between groups. Effect size was interpreted as follows: d = 0.80 (large), d = 0.50 (medium), d = 0.20 . Statistical significance set a priori at p < 0.05. The Statistical Package for the Social Sciences  was used for all the statistical analyses.No significant differences were found for age, height, weight, and BMI between the groups (p > 0.05). The results of mixed model analysis of variance indicate that the group × time interactions and main effect for group were not significant (p > 0.05) for all measurement outcomes. However, there was a main effect for Time . Such that the post-intervention had more hip PROM in both legs  than the pre-intervention  in the experimental group. Also in this group, subjects exhibited less pain in the post-intervention (3.12 ± 1.28) than in the pre-intervention (4.70 ± 1.11) based on the VAS index, and exhibited less disability in the post-intervention (16.66 ± 5.86) than in the pre-intervention (29.51 ± 8.66) based on the ODI index. But no significant difference was found between before and after the intervention in the control group  in the experimental group. Therefore, the results of this study can confirm the results of previous studies . AccordiThis study has several limitations. First, because the age and sex of the patients were set limited to 25 to 40 years females, our data cannot be generalized to all ages and sex. Second, in our study, the menstrual cycle of the participants in the pre-test and post-test stages was not taken into account and because it is possible for some people to experience NSLBP within their period, it is suggested that the factor be considered in future research. Third, the stretching exercise program was only compared with a no stretching exercise program rather than a placebo condition; thus, Improvement in the evaluated parameters may relate to a placebo effect. Forth, results can be affected by VAS reliability.The results demonstrated a significant difference in PROM, pain, and disability after 8 weeks of hip static stretching exercises in participants with NSLBP and limited hip extension. Therefore, it would be reasonable to infer that NSLBP might be partly related to hip flexors tightness.


Health professionals’ (HPs) knowledge of recommended guidelines for physical activity (PA) is thought to influence the advice they provide to their patients. Little is known about the knowledge or provision of PA advice by HPs working with haematological cancer patients. This study examined awareness of PA guidance, beliefs and practices in provision of advice given by UK HPs working with haematological cancer patients.Online survey including questions on awareness of PA guidance, levels of agreement/disagreement with statements related to PA in haematological cancer and reported provision of advice in practice. Open text responses sought detail regarding guidance knowledge and exampled advice given by respondents. Predictors of familiarity of guidance and provision of advice were examined.Complete responses were received from 156 professionals, mostly nurses, allied HPs and doctors. Many (31%) reported knowing relevant guidance and nearly half (48.6%) reported routinely giving PA advice. Nurses and allied AHPs give advice to more patients than doctors and knowledge of guidelines among doctors was poor.Beliefs of haematology professionals regarding the role of PA during and after treatment for haematological cancer were generally positive. Those reporting familiarity with guidance were more likely to give advice. Misalignment exists between guidelines and advice given by professionals to their patients. Increasing knowledge of guidelines among HPs, including nurses, may lead to increased provision of PA advice and promotion of PA to more of their patients. HPs education in haematology on PA guidance tailored to professional group is needed. Five-year survival rates for haematological cancers are estimated to be 60% and 250,000 people are currently living with haematological cancer in the United Kingdom (UK).10–12General promotion of positive messaging and endorsement of PA by healthcare professionals (HPs) could be influential in encouraging more people living with haematological cancer to be physically active. HPs have a key role in providing evidence-based information to people living with and beyond cancer regarding their condition, treatment options and promoting healthy lifestyle during and after cancer treatment.Therefore, the purpose of this study was threefold; i) to examine awareness of PA recommendations, ii) explore beliefs surrounding the role of PA during and after treatment and iii) to understand practices in provision of advice given to patients by HPs working with people living with and beyond haematological cancer in the UK. Predictors of familiarity of PA guidance and provision of advice to patients were also examined.Data was obtained via an anonymous online survey using the Opinio platform. HPs working in a UK cancer setting in roles that had direct contact with patients with a haematological cancer diagnosis were eligible. Responses were sought from doctors, nurses, allied health professionals (AHPs), pharmacists, research practitioners and support/auxiliary health care staff. The study was approved by the University College London (UCL) Research Ethics Committee (reference 14783/001) and conducted in accordance with the principles stated in the Declaration of Helsinki. Participants were informed of the aims of the study and that they could participate anonymously, prior to providing informed consent and accessing the survey.A number of professional organisations were approached to distribute the survey to their members. Seven agreed, including the British Haematology Society, the UK Oncology Nursing Society, the Association of Chartered Physiotherapists in Oncology and Palliative Care, the British Dietetic Association Oncology Group, the Society of Radiographers, the British Oncology Pharmacy Association and the European Society for Blood and Marrow Transplantation Nurses and AHPs Group. An introduction and online link to the survey was sent to each organisation, who either forwarded it to their members via email, placed it on their websites or shared it on social media. The survey link was also shared by the research team on social media platforms. The survey link was open for 200 days between April and October 2019.The survey was based on previously published studies of HPs conducted in the UK and IrelandThe survey was piloted in paper format and tested on three HPs working at a local NHS hospital. These participants were asked to complete the survey questions whilst “thinking aloud” to gather feedback on the appropriateness and understanding of the questions. Finally, an online version of the survey was piloted using the Opinio platform on a small varied sample of HPs from a local NHS hospital, including AHPs, a doctor and a nurse, and research colleagues.Demographic questions related to age, gender and professional group. Professional questions explored time in current role, haematological cancer diagnoses of patients in their care, clinical setting type and location by region. Respondents own self-reported PA was assessed with the questions: “On average, how many days per week did you engage in moderate to strenuous PA ?” and “How long is your average session of moderate to strenuous PA in minutes ?”.HPs familiarity with guidelines was asked with the question: “Are you familiar with any PA or exercise guidelines that are relevant for cancer patients?”. If respondents selected ‘yes, I know of relevant guidelines’, they were routed to an open text question: “please give some details of the PA guidance that you know? ”.HPs were asked to share their level of agreement or disagreement with a number of statements related to PA in the context of people living with haematological cancer. These statements were presented in two matrix style questions; one asking HPs to respond to the statements while considering patients during treatment for haematological cancer, the second asked them to respond to the statements while considering patients after completion of treatment for their haematological cancer.In relation to HPs giving advice to their patients, HPs were asked the question: “Do you give advice regarding PA to your patients with blood cancer?”. The proportion of patients they give advice to and the timing of advice were assessed with the following questions; “Can you estimate how many of your patients with blood cancer you give advice about PA to?” and “When do you commonly give advice about PA to your patients with blood cancer?”.To gather detail on the information that HPs provide to their patients, survey participants were asked: “Please give an example of information or advice you give about PA to patients with blood cancer?”. This open text question had an unlimited free textbox response and could be skipped without providing a response.Survey data was downloaded from Opinio into the statistical package SPSS  for analysis. Descriptive statistics were generated to describe proportions of respondents overall and by professional group, demographics, professional setting, awareness of PA guidelines and provision of PA advice. Due to the limited numbers of respondents across professions, some underrepresented groups were categorised as “other”  and statistical analyses focussed on the three largest professional groups who responded; nurses, AHPs and medical professionals. Predictors of familiarity of PA guidance were examined using an ordinal logistic regression including HP familiarity with guidelines, professional group, time in current role and HPs self-reported PA. Provision of advice to patients were explored using a binomial logistic regression examining demographic predictors  and awareness of PA guidelines on reported proportion of patients given PA advice. For the second model the dependent variable was dichotomised into provision of advice to less or more than 50% of patients and also only included the three largest professional groups.Responses to the open text survey questions were transferred into NVivo  and coded line by line. To map the range and nature of open text responses a process of framework analysis was followed using five key stages; familiarisation of data, identifying a thematic framework, indexing, charting and mapping and interpretation, as outlined by Ritchie and Spencer (2002).21The exact response rate for the survey is not known as the online link was shared by distributing organisations. The survey link was accessed 244 times. Two hundred and nineteen HPs started the survey, 206 (94%) completed all demographics questions and 196 (89.5%) completed at least one question related to the aims of the study. Of these, 156 (71%) completed the whole survey. The survey had at least three responses from each region of England and at least six from each of the UK home countries , the greatest number of respondents were from the London region . Most respondents  worked in a specialist oncology/haematology centre treating haematological cancers and carrying out stem cell transplantation. The characteristics of the respondents are shown in Thirty-one per cent (n=60) of respondents knew relevant PA guidance. Thirty-seven per cent (n=72) reported being aware there was guidance but did not know what it was and 33% (n=64) were not aware of any. Awareness of guidelines by professional group is presented in Of the 60 respondents who reported knowing relevant guidance, 43 (71.7%) provided details of the guidance they knew in their open text response. Thirty-four (56.7%) named a source of guidance or guideline, the most frequently named source of guidance was from charities, with Macmillan Cancer Support most commonly mentioned, followed by international sources including the American College of Sports Medicine (ACSM) and the European Society for Clinical Nutrition and Metabolism. The Chief Medical Officer/Department of Health guidelines were mentioned by only four respondents. Nineteen respondents provided details related to appropriate principles or components of PA guidance . When comparing the three largest professions , who responded to the survey, nurses more commonly referred to charity sources of guidance but only five named a relevant PA guideline and three mentioned principles of PA guidance, whereas 16 AHPs named a relevant PA guideline, 15 mentioned principles of PA guidance. There were no open text responses from medical professionals as none reported knowing relevant guidelines in the previous survey question.Most respondents agreed that patients with haematological cancer should be encouraged to be physically active, that regular exercise can alleviate symptoms of fatigue, can improve QOL and that structured exercise should be part of the treatment pathway for patients during treatment for haematological cancer. When questioned about confidence in making recommendations to patients, overall more than half of all respondents disagreed with not feeling confident (57.6%) . Among tSimilar patterns of agreement were seen for statements regarding the role of PA for patients with haematological cancer on completion of treatment . Slightl48.6% (n=85) of respondents who answered questions related to provision of advice reported routinely giving advice regarding PA to most of their patients. 26.3% (n=46) respondents reported that they only provide advice if their patients request information on PA. A small number of respondents reported only providing PA advice to patients they think would benefit from it  and the most commonly cited reasons were if patients were fatigued, deconditioned or frail, have comorbidities that benefit from regular PA and/or have treatment-related symptoms .Table 4“Differences between professional groups can be seen in When questioned on the proportion of patients that HPs give PA advice to, overall 37.6% (n=56) reported they provide advice to less than 25% of their patients. 29.5% (n=44) respondents reported giving advice to greater than 75% of their patients. When separated by professional group, half of AHPs reported giving PA advice to more than 75% of their patients, nursing professionals had an even spread across all responses and the majority of medical professionals (51.7%) reported giving advice to less than 25% of their patients. Surveyed HPs reported that during treatment is when they most commonly provide PA advice to their patients (112 responses), then on completion of treatment (83 responses) and during survivorship/follow up or during maintenance treatment (both 69 responses) .Table 5“A binomial logistical regression model was used to examine the role of professional group, time in role and guideline awareness on provision of PA advice to more than 50% of patients. Respondents who reported knowing relevant PA guidelines for people living with and beyond cancer had higher odds of providing PA advice to more than 50% of their patients (OR 3.4 (95% CI 1.1–10.6), p=0.038), but there were no other significant differences among professional group (AHPs: OR 1.8 (95% CI 0.67–4.74), p=0.250), nurses: (OR 1.6 (95% CI 0.47–5.39), p=0.462) or time in role (OR 1.3 (95% CI 0.63–2.71), p=0.477).When asked to provide an example of information or advice they give to patients regarding PA, 116 participants provided a response to the open text question. Themes that were concluded from the analysis of open text responses indicated HPs focussed the advice they give around promotion of usual activities, sharing and emphasising the benefits of PA, using a settings  and/or timing in treatment-based approach to advice. There was repetition of cautious or restrictive advice regarding intensity and type of PA advised and an emphasis on providing resources  and/or signposting to others or other services . Examples of captured quotes are detailed in This survey-based study explored haematology HPs’ awareness of PA recommendations, their beliefs about the role of PA and their reported provision of advice given to people living with and beyond haematological cancer during and after treatment. To our knowledge this is the first published study to investigate professional attitudes and practices among a sample of HPs dedicated to haematological cancer. Awareness of PA recommendations for patients was modest with a third of respondents reporting no awareness of any PA guidance, which is in keeping with other cancer HP surveys. The haematology HPs surveyed largely held positive beliefs about the benefits and promotion of PA for haematological cancer patients both during and after their treatment and their reported provision of advice to their patients regarding PA was promising, with approximately half of respondents reporting they give advice to about half of patients in their care, however professional groups differences were evident.Awareness of PA recommendations among respondents was varied with similar proportions confirming they knew of relevant PA guidance, or were aware guidance existed but not what it was, or reported being unaware of any existing guidance. These findings are in keeping with lifestyle advice surveys conducted among HPs working in oncology settingsRecommendations for PA specifically related to people living with and beyond cancer have been available since 2010 when the ACSM published their roundtable recommendations, which largely followed general population guidance such as those laid out by the Chief Medical Officers’ PA guidelines in the UK,22Across professions, approximately half of HPs surveyed reported that they give PA advice routinely to their patients with haematological cancer, which is similar to levels of recommendation by HPs working with breast and prostate cancer patients.AHPs providing recommendations on PA to larger proportions of patients was expected. Another small survey study of cancer physiotherapists, reported figures as high as 82% of participants who recommend or use exercise specifically for people with haematological cancer.22Results from this study demonstrate general positive believes that PA and exercise should be encouraged as part of treatment and follow-up for people living with and beyond haematological cancer and that nearly all respondents provide PA advice to at least some of their patients. Analyses of open text responses regarding what guidance HPs were aware of and what advice they give to patients did not always align. Few respondents provided a source or details of the guidance they knew, but most responses received were appropriate, including charity sources of advice or details of principles laid out in evidenced recommendations. Themes emerging from the analysis of advice given did indicate a mostly positive approach to promoting usual activities, the benefits of PA and signposting to resources. However, there was also a theme of cautionary or conservative advice given often advising limiting of exercise intensity or type to people living with and beyond haematological cancer. This may be a reflection of the varied professions who responded to the survey and may indicate a need for stronger referral links or embedding of professionals trained in exercise prescription working within haematological cancer MDTs. Future research related to this survey intends to explore these themes further through a qualitative study of HPs working in haematology.In the delivery of cancer care, HPs are recognised as crucial to endorsement and promotion of PA and lifestyle advice,35This survey is the first of its kind to focus on haematological cancer HPs in the UK but has some limitations. Firstly, it is not possible to ascertain a response rate due to the online distribution of the survey, also it received a modest number of respondents and therefore analyses of professional groups was limited. Secondly, research of this kind may naturally attract HPs with a positive view of the role of PA themselves or who are more aware of growing social desirability to promote PA particularly among people living with long-term conditions, such as people living with and beyond cancer


Total knee arthroplasty (TKA) is associated with moderate-to-severe postoperative pain despite multimodal opioid-sparing analgesia. Pain catastrophising or preoperative opioid therapy is associated with increased postoperative pain. Preoperative glucocorticoid improves pain after TKA, but dose-finding studies and benefit in high pain responders are lacking.−1 or intermediate-dose dexamethasone 0.3 mg kg−1 in 88 patients undergoing TKA with preoperative pain catastrophising score >20 or regular opioid use was designed. The primary outcome was the proportion of patients experiencing moderate-to-severe pain (VAS >30) during a 5 m walk 24 h postoperatively. Secondary outcomes included pain at rest during nights and at passive leg raise, C-reactive protein, opioid use, quality of sleep, Quality of Recovery-15 and Opioid-Related Symptom Distress Scale, readmission, and complications.A randomised double-blind controlled trial with preoperative high-dose intravenous dexamethasone 1 mg kgvs intermediate dose, 49% vs 79%; P<0.01), along with pain at leg raise at 24 and 48 h . C-reactive protein was reduced in the high-dose group at both 24 and 48 h (both P<0.01). Quality of Recovery-15 was also improved (P<0.01).Moderate-to-severe pain when walking 24 h postoperatively was reduced (high dose −1 i.v., dexamethasone 1 mg kg−1 reduced moderate-to-severe pain 24 h after TKA and improved recovery in high pain responders without apparent side-effects.When compared with preoperative dexamethasone 0.3 mg kgNCT03763734. Written informed consent was obtained from all subjects before entering the study.This double-blind RCT was designedDexamethasone was administered as a single i.v. bolus dose preoperatively immediately after spinal anaesthesia. Dexamethasone dose (HD or ID) was blinded upon arrival at the operating theatre, and all personnel involved in treating the participants were blinded to allocation. Surgery was performed in standardised fast-track settings, including pre- and postoperative tranexamic acid, LIA, postoperative compression bandage, absence of drains, and the use of a standardised mobilisation protocol encouraging early mobilisation. Perioperative antibiotic regimen consisted of i.v. dicloxacillin 2 g at start of surgery and repeated if body weight >80 kg or if length of surgery >2 h. Dicloxacillin was repeated as 1 g tablet 8 h after end of surgery. Cefuroxime replaced dicloxacillin in patients with allergy.Surgical procedure included midline incision, medial parapatellar arthrotomy, using measured resection technique with release as needed, osteotomy with extramedullary guide on tibia, intramedullary guide on femur, and patellar resurfacing in all cases at the first centre and in selected cases in the second centre. No computer-aided navigation was used. Femoral tourniquet was used optionally at one site. Patients were discharged to their homes when fulfilling the standard functional discharge criteria. In-hospital only thromboprophylaxis was used in patients with length of stay (LOS) <5 days.−1, celecoxib 200 mg (12 h)−1, and oral morphine 5–10 mg or other opioids in equivalent doses as rescue opioids.All subjects underwent surgery in planned spinal anaesthesia with hyperbaric bupivacaine 0.5% (10–12.5 mg) and perioperative sedation with propofol optional. Multimodal analgesic standard regimen was initiated on day of surgery with paracetamol 1 g and celecoxib 400 mg, and continued postoperatively with paracetamol 1 g (6 hourly)From January 2019 to August 2020, all patients undergoing elective unilateral primary TKA were screened for inclusion. Patients with Pain Catastrophizing Scale (PCS) scoreSubject characteristics data included prior opioid treatment and PCS score, evaluating the level of or tendency to catastrophising thinking,A pain dairy was completed by the patient on Days 2–7 reporting VAS pain at rest, night, and 5 m walk test, along with quality of sleep, fatigue, nausea, and dizziness all on NRS . Analgesics and anti-emetics use and overall satisfaction  were also reported. Follow-up was performed at 14, 30, and 90 days using the electronic patient record or by phone. The Clavien–DindoThe primary outcome was the proportion of subjects reporting moderate-to-severe pain (defined as VAS >30) on a 5 m walk test 24 h postoperatively. Secondary outcomes were proportion of patients reporting moderate-to-severe pain (VAS >30) at passive leg raise, at rest, and at night; cumulated pain (cumulated pain was reported VAS scores added from Days 0–2 and 2–7); use of rescue opioids and anti-emetics; quality of sleep 0–48 h and Days 0–7; CRP before and at 24 and 48 h postoperative; QoR-15 and OR-SDS at 0–48 h; quality of sleep, fatigue, nausea, and dizziness on Days 2–7; and overall satisfaction with analgesic treatment. Also included was hospital LOS, readmissions, medical events and complications, and 90 day mortality.9 11 We estimated a relative reduction in pain from the ID of glucocorticoids, similar to that found in a previous study,n=88).No specific data exist on the pain scores of HPR patients undergoing TKA with ID glucocorticoids. Previous studies have found a prevalence of VAS >30 at 24 h walk test of 0.9 in patients with high PCS, and 0.86 in patients with chronic preoperative opioid use, without preoperative glucocorticoid treatment.vs ID, with an 8:8 allocation rate, was packed in 88 opaque envelopes by two unblinded personnel not otherwise participating in the study. Screening and inclusion were done by blinded primary investigators and study personnel, and included participants were consecutively assigned the next randomisation envelope on-site. All participants were also blinded. Randomisation envelopes were opened by unblinded personnel when preparing the study drug ahead of surgery and sealed again afterwards for storage until all study analyses were completed. The study drug was mixed in a saline container to a total volume of 100 ml, and given to the patient after administration of spinal anaesthesia. The 100 ml containing the study drug was blinded for all personnel and participants.A computer-generated randomisation protocol of 88 planned participants, 44 in each group HD t-test and presented as means and standard deviations, or Mann–Whitney U-test if appropriate. We used SPSS statistics version 25  and RStudio version 1.0.153 . All data were analysed before unblinding.The VAS scores were reported as median and inter-quartile range. Continuous data were tested using From February 13, 2019 to August 26, 2020, a total of 1037 patients were assessed for inclusion, and 88 patients were included and randomised. Four patients did not receive the allocated intervention because of preoperative change of type of surgery or anaesthesia   24 h after surgery was significantly lower in the HD group compared with the ID group in a 5 m walk test (49%  P<0.01) , and VASvs ID  at both 24 and 48 h, respectively. No significant difference was found at 5 m walk test at 48 h and at rest or at sleep (see The proportion of subjects reporting moderate-to-severe pain (VAS >30) with passive leg raise was lower in HD leep see . From Daleep see .vs ID 86 [69–143]; P=0.05, and at passive leg raise HD 23 [0–81] vs ID 67 [28–11]; P=0.05, but no difference at 5 m walk test , or at night . No difference was found in cumulated pain over Days 2–7 at rest, at night, or at 5 m walk test.Cumulated pain Days 0–2 showed a difference at rest  and 48 h  (Inflammatory response measured by CRP was significantly lower in the HD group both at 24 h (13 [8–23] mg L P<0.01) .Fig 4Chavs 83 [46–111]; P=0.06) .Cumulated use of opioids  on Days 0–2 showed no significant difference between HD and ID (median 51 [30–90]  P=0.06) , nor cumvs ID. Cumulated anti-emetic use in the HD vs ID groups at 48 h was 8 mg vs 36 mg (P=0.21), and the incidence of subjects in need of anti-emetic at 24 h was  and at 48 h was .Ondansetron was the only used anti-emetic, but without difference between the groups HD vs ID at 48 h . Also, delta value of total score from preoperatively to 24 h was higher in the HD group , and from preoperatively to 48 h . Subgroups 1, 4, and 5 had significantly higher scores at 48 h  in favour of HD . Length of stay was similar, P=0.44, with only one vs two subjects having LOS >2 days. One subject in the HD group vs two in the ID group were readmitted to the hospital within the first week after surgery, because of suspected prosthetic joint infection (not verified) and problems with pain and mobilisation. Medical complications at 90 days in the two groups consisted of two skin infections (herpes zoster and erysipelas) in the HD group and one subclavian vein thrombosis in the ID group. Surgical complications included one joint infection demanding revision surgery, one wound leakage stopped by compression bandages, and one manipulation under anaesthesia in the HD group vs one deep tissue infection needing antibiotics and one patellar dislocation needing revision surgery in the ID group. Clavien–Dindo grade (I/II/IIIb) in the HD group vs the ID group was 1/0/2 vs 1/0/1.Overall satisfaction with analgesic treatment (Days 0–7) was similar between the groups (vs 0.3 mg kg−1) of dexamethasone in TKA and the first to specifically study an high pain responder population. The incidence of moderate-to-severe pain (primary outcome) was significantly reduced using high-dose dexamethasone i.v.This is the first study to compare different high doses  as factors associated with persistent pain and prolonged postoperative opioid use after TKA.The incidence of moderate-to-severe pain was reduced to 49% using HD DXM, which is still high and calls for a more specialised approach in treating the HPR population. Earlier studies of specific interventions in HPR patients were limited to one study, excluding patients who receive opioid medication, showing antidepressants (selective serotonin reuptake inhibitors) to have no or limited effect on painThe demonstrated additional analgesic effect in the HD group was correlated with a further attenuated CRP response 24 and 48 h after surgery compared with ID, similar to the relative effects seen when comparing an ID glucocorticoid dose with placebo in TKA.The QoR-15 showed statistically significant differences, favouring the HD group. This could be explained by the analgesic effect and reduced inflammation facilitating decreased fatigue, as QoR-15 showed significant improvements in physical comfort and emotional state subgroups, but psychotropic effects of glucocorticoids may have contributed to the physical well-being.Cumulated postoperative use of rescue opioids from surgery to 48 h did not achieve statistical significance between the two groups, although a tendency towards a lower use was seen in the HD group, which could be a Type 2 error, as the study was not powered to show differences in opioid consumption.In a recent large systematic review on postoperative pain treatment in TKA,The HPR group might be at higher risk of both continued prescription of opioids during their recovery and subsequently at higher risk of opioid addiction as a consequence of their higher postoperative pain levels, especially for patients with preoperative opioid use.−1 equivalents).,In HD glucocorticoid treatment, potential side-effects need consideration. Previous studies found no increased risk of infections with ID  led to a significant reduction in patients with moderate-to-severe pain 24 h after surgery, compared with intermediate dose (DXM 0.3 mg kg−1 i.v.), and reduced CRP response together with improved quality of recovery. However, a clinical pain problem still resides in this high pain responder population, as 50% of patients registered VAS >30 during a brief walk at 24 h after surgery.In conclusion, an high dose of preoperative steroids (DXM 1 mg kgDrafting of protocol: NIN, HK, HH, KG, NBFWriting of paper: all authorsApproval of paper: all authors.


This observational study aimed at investigating pain in stroke patients with upper limb spastic dystonia. Forty-one consecutive patients were enrolled. A 0–10 numeric rating scale was used to evaluate pain at rest and during muscle tone assessment. Patients were asked to indicate the most painful joint at passive mobilization . The DN4 questionnaire was administered to disclose neuropathic pain. All patients were assessed just before and 1 month after incobotulinumtoxin-A treatment. Pain was present in 22 patients, worsened or triggered by passive muscle stretching. DN4 scored < 4 in 20 patients. The most painful joints were wrist–fingers in 12 patients, elbow in 5 patients and shoulder in the remaining 5 patients. Both elbow and wrist–fingers pain correlated with muscle tone. BoNT-A treatment reduced pain in all the joints, including the shoulder. We discussed that nociceptive pain is present in a vast proportion of patients with upper limb spastic dystonia. BoNT-A treatment reduced both spastic dystonia and pain in all the joints but the shoulder, where the effect on pain could be mediated by the reduction of pathological postures involving the other joints. In patients with upper motor neuron syndrome (UMNS), velocity-dependent hypertonia (greater resistance is experienced with fast stretches) is a common clinical sign . The terMany studies have shown that pain is common after stroke, affecting up to 50% of stroke survivors, with the majority experiencing pain on a daily basis ,12. SeveThis study represents the first attempt to investigate pain in post-stroke patients affected by upper limb spastic dystonia. Our specific objectives were to assess pain prevalence, pain localization, pain type (nociceptive or neuropathic) and the effect of the toxin on pain.From 1 January 2021 to 31 July 2021, 41 post-stroke patients with upper limb spastic dystonia referred to our outpatient clinic. All 41 patients were enrolled in the present study . Demographics and clinical data are shown in According to the inclusion criteria, all patients showed pathological postures determined by muscles showing increased stretch reflex excitability . In 34 patients (83%), both pathological postures of the shoulder, elbow, forearm, and wrist joints (Hefter’s patterns) and pathological postures of the fingers (affecting digits 2–5 and/or thumb) were found. Four patients (10%) presented only pathological finger postures (Hefter’s pattern 0), while the remaining 3 patients (7%), all with Hefter’s pattern IV, showed no pathological finger posture (F-and T-patterns 0) .Patients 1–9 scored > 0 on the pain numeric rating scale at rest (PNRS-rest); in two of them, pain was severe. Patients 1–22 scored > 0 on the pain numeric rating scale at passive mobilization (PNRS-mobilization); in 14 of them, pain was severe. In 20 patients, they scored < 4 in the DN4 questionnaire; in the remaining 2 patients, DN4 scored 4.n = 26, women n = 15, p = 0.004). No difference in PNRS-mobilization scores was found between patients with ischemic and hemorrhagic stroke , nor between patients with right- and left-affected sides of the body .PNRS-mobilization scores were higher in women than in men .Age and PNRS-mobilization scores did not correlate .In 5 patients, shoulder was the most painful joint (shoulder-pain dominant). In four of them, the modified Ashworth scale (MAS) of shoulder adductors scored 0. Only the subject scoring MAS > 0 was treated with incobotulinumtoxin-A in shoulder adductors in addition to other muscles of the upper limb, while the remaining four patients were treated only in other muscles of the upper limb see the . In thesn = 24, Rho = 0.5, p = 0.02).In five patients, the elbow was indicated as the most painful joint (elbow-pain dominant). In all of them, forearm flexors and/or forearm pronators MAS scored ≥ 2. In all of them, incobotulinumtoxin-A was injected in forearm flexors and/or forearm pronators. In these 5 patients, PNRS-mobilization scores and MAS score directly correlated , but the 6 patients reporting severe pain scored higher MAS than those with mild pain, and the 19 patients with no pain .In 12 patients, the wrist and finger joints were indicated as the most painful ones (wrist–fingers-pain dominant). In all of them, the wrist and/or finger flexors MAS score was ≥ 2. In all of them, incobotulinumtoxin-A was injected in wrist flexors and/or finger flexors. In these 12 patients, PNRS-mobilization scores did not correlate with wrist–fingers flexors MAS scores (p = 0.0007), forearm pronators , wrist flexors , and finger flexors . Concomitantly, pathological postures changed in most patients. Both PNRS-rest  and PNRS-mobilization  scores decreased at T1 .Of the remaining 17 patients (5 elbow-pain dominant and 12 wrist–fingers-pain dominant), the MAS score remained unchanged in 5 patients, and the PNRS-mobilization score in 4 of them. In contrast, in the 12 patients with decreased MAS scores, also PNRS-mobilization scores decreased, except for 2 patients. However, no correlation was found between the decrease in MAS scores and the decrease in PNRS-mobilization scores . Nine patients (22%) complained of pain at rest that increased during passive muscle stretching, with thirteen patients (32%) only during passive muscle stretching. The sensitivity to pain from passive muscle stretching points toward a nociceptive nature of pain, as confirmed by the DN4 questionnaire scores, that disclosed a neuropathic component of pain only in two patients. Therefore, pain accompanying upper limb spastic dystonia in stroke patients is predominantly nociceptive and has a very infrequent neuropathic component.The intensity of pain proved greater in women than men. This finding is in line with much of the literature. Sex difference in pain perception has been well established, and women, on average, report more intense pain, more frequent pain, and pain of a longer duration than men .Among the five elbow-pain dominant patients, four had Hefter’s IV pattern. Since this is a relatively rare pattern (only found in 10 out of the 41 enrolled patients), it appears to be more frequently associated with elbow pain than the other patterns involving elbow flexion. In our series, none of the patients exhibiting Hefter’s III pattern (23 of the 41 enrolled patients) were elbow-pain dominant. Since the main postural difference between Hefter’s III and IV patterns is the pronated forearm, reasonably the pain derives from the composite and concurrent mechanic action exerted at the elbow joint by forearm flexion and pronation. In these five patients, pain and tone scores correlated, indicating than both share some common element.In the 12 wrist–fingers pain-dominant patients, muscle hypertonia was significantly more pronounced in those with severe pain than in those with mild or no pain. Nevertheless, the direct correlation between pain and muscle tone was not significant. Taken together, pain that results from elbow-pain dominant and wrist–fingers-pain dominant patients suggests that elbow pain and wrist–fingers pain in patients with upper limb spastic dystonia has some connection with the tone of the muscles acting on the painful joints. Whereas such connection is clear-cut for the elbow, it needs to be confirmed in a larger population for wrist and fingers. One possible factor for this difference is that the elbow is a multi-movement single-joint system, whereas wrist–fingers are a multi-movement multi-joint system, thus obeying distinct biomechanical constraints.In patients with spastic dystonia, muscle hypertonia and pain likely exert a mutual influence at various levels. Tonic muscle contraction—the dominant trait of spastic dystonia that produces muscle hypertonia—may induce pain by itself. When the actively contracted muscle is passively stretched, pain increases. The same happens in healthy subjects who exert eccentric muscle contraction when they oppose to forceful stretching . The abnIn this series of patients, incobotulinumtoxin-A treatment induced a significant pain reduction. Toxin analgesic effect in patients with muscle overactivity can be mediated by two mechanisms. Action at the presynaptic terminals of the spinal motor neurons blocks the release of acetylcholine, thus reducing excessive muscle contractions and contraction-related pain. Action at the nociceptive terminals of the peripheral afferent fibers blocks the release of neurotransmitters and neuropeptides involved in nociception, thus reducing nociceptive pain .After incobotulinumtoxin-A treatment , only thOf the five shoulder-pain dominant patients, only one manifested hypertonia in muscles acting on the shoulder joint. In stroke patients, previous works suggest that the highly disabling condition known as “hemiplegic painful shoulder” has multifactorial pathogenesis. Shoulder pain has been associated with soft tissue injury related to subacromial bursitis, bicipital tendinopathy, glenohumeral subluxation, and rotator cuff pathology ,22. FourThis is an observational study. The effect observed on pain could, at least in part, be due to a placebo effect. Spastic dystonia was assessed clinically to reproduce the most frequent real-world clinical setting. The sample size was relatively small, thus limiting the generalization of the results. Finally, we cannot exclude that at the time of the first assessment (T0), some patients were still under the effect of the previous injection, thus influencing pain intensity and prevalence.Strength of this study is that the same investigator assessed all patients consecutively,This longitudinal observational study was conducted at neuro-rehabilitation outpatient clinic of the Department of Neuroscience, Ospedale Policlinico San Martino-IRCCS, Genova, Italy.From 1 January 2021 to 31 July 2021, all stroke patients with upper limb spastic dystonia were consecutively enrolled. Spastic dystonia was diagnosed when the following two clinical signs were found: (1) upper limb pathological resting postures ; (2) velocity-dependent hypertonia and/or increased deep tendon reflexes in the muscle groups determining the observed postures .The present study has been carried out in accordance with The Code of Ethics of the World Medical Association (Declaration of Helsinki) for experiments involving humans; written informed consent was obtained from all participants. This observational study was notified to the local ethics committee “Comitato Etico della Regione Liguria” and is scheduled for approval on 13 December 2021 (study ID 11983-n. 691).Among the enrolled patients, those treated with BoNT-A were assessed twice, before (T0) and after treatment (T1). Those not treated were assessed only once (T0).The tone of muscles acting at the shoulder, elbow, wrist, and finger joints was evaluated using the modified Ashworth scale (MAS), a 6-point scale ranging from 0 (no increase in tone) to 4 (limb rigid in flexion or extension) . Muscle Upper limb postures were categorized by means of two different descriptors. Postures involving the shoulder, elbow and wrist joints were classified according to the 5 patterns described by Hefter and associates . Finger By using the disability assessment scale (DAS) , four arPain was evaluated using a numeric rating scale (PNRS), with 0 being “no pain” and 10 being “the worst pain imaginable” . PatientThe DN4 questionnaire was used to disclose neuropathic pain. The questionnaire includes seven symptoms and three physical examination items. A score of 1 is given to each positive item and a score of 0 to each negative item. Patients scoring ≥ 4 are considered to have neuropathic pain .Following our usual clinical practice, to relieve upper limb spastic dystonia each patient was considered for possible BoNT-A treatment. In those patients deemed candidates for treatment, incobotulinumtoxin-A  was injected in the hypertonic muscles of the upper limb under ultrasound guidance. The muscles to be injected and toxin doses were determined in each single patient, according to the clinical picture, with the aim to reduce disability due to muscle hypertonia and/or pain, and to evaluate possible effects on pain itself.We used the Statistical Package for the Social Sciences (SPSS), SPSS Italia, Bologna, Italy, for all analyses. The Mann-Whitney test was used to assess the effect of gender , stroke type (ischemic/hemorrhagic) and the affected-body side (right or left) on PNRS scores. Furthermore, the Mann–Whitney test was used to compare MAS scores in patients with high pain (NRS > 6) in comparison to those with low pain or no pain (NRS < 7).The Spearman rank test was used to correlate age and PNRS scores. The test was also used to correlate MAS and PNRS scores.The Wilcoxon signed rank test was used to calculate changes in MAS and PNRS scores between T0 and T1.


Medical cannabis (MC) is becoming increasingly popular for the treatment of chronic pain conditions. In this study, we evaluated the effect of MC treatment on pain level and quality of sleep of patients with different medical conditions at the rheumatology clinic.  Patients licensed for the use of MC at the rheumatology clinics at different settings were located and contacted. Their demographic and clinical parameters were documented, including type of medical cannabis consumed, way of consumption, and current monthly consumed amount. These patients were contacted by phone and asked about the effect on pain level and quality of sleep.  A total of 351 patients were located, and 319 completed the questionnaire. Mean age was 46 ± 12 years, 76% were female, 82% had fibromyalgia, ∼9% had mechanical problems, ∼4% had inflammatory problems, ∼4% had neurological problems, and ∼1% had other problems. The average monthly consumed dose of MC was 31, 35, 36, and 32 g, with mean pain level reduction of 77%, 82%, 83%, and 57%, and mean sleep quality improvement of 78%, 71%, 87%, and 76% among patients with fibromyalgia, mechanical, neuropathic, and inflammatory problems, respectively. Mean THC and CBD contents were 18.38% ± 4.96 and 2.62% ± 4.87, respectively. The THC concentration, duration of MC consumption, and MC consumption dose had independent significant correlations with pain reduction while only the duration of MC consumption had an independent significant correlation with sleep quality improvement.  MC had a favorable effect on pain level and quality of sleep among all spectrums of problems at the rheumatology clinic. Medical cannabis (MC) is gaining increasing popularity as a treatment for severe cases of chronic pain syndromes, including musculoskeletal and neuropathic conditions . It has Currently, despite the introduction of biological treatment for different inflammatory rheumatic diseases, including rheumatoid arthritis, psoriatic arthritis, and ankylosing spondylitis, a small proportion of the patients with these conditions either do not or only partially respond to the biological treatment, with their ongoing pain affecting their sleep. These biological treatments are associated with increased risk of infection, including herpes zoster and/or tuberculosis and even increased incidence of malignancy . Some paWith the expanding nonsurgical treatments of degenerative musculoskeletal disease, rheumatologists are also dealing more and more with patients with such ailments at the rheumatology clinic. Degenerative diseases are the most common musculoskeletal problems, where painkillers of different strengths are the main treatment option. Some people with such problems also consume narcotics . RecentlThe adverse effects of MC have been reported to be mostly mild and tolerable, and some have been reported to be transient, with a relatively low dependency rate or tolerance . Such adCannabis is still considered a prohibited drug in Israel, and a license is issued for its use by designated medical doctors or by the Israeli MC Agency (IMCA). It is indicated for a wide variety of clinical issues but mainly for malignancy-associated symptoms/signs, resistant chronic pain syndromes, resistant neurologic problems, and resistant mechanical problems.Here, we summarize all the patients registered at rheumatology clinics who were treated with MC to prospectively evaluate the effect of MC on their pain level and quality of sleep.All the patients who had been treated with MC in the registry of two outpatient rheumatology clinics, Laniado Hospital in Netanya and Nazareth Hospital in Nazareth, in addition to those in the registries of the rheumatology clinics of four health insurance services in Israel  followed by the first author, were located . About 450 patient visits are seen monthly in these clinics. Only patients who used MC for at least two months prior to the MC reform in May 2019 were included in the study. The reason behind this is that prior to MC reform, patients were able to change the type of MC they consumed within few weeks if the cannabis was not beneficial and also had free guidance and assistance in how to use MC. Following the reform, patients had no free guidance and support and took many months for them to be able to change the type of cannabis if these types were not helpful, especially the new users of MC. Therefore, we wanted to guarantee that all the patients in our study had the chance to change their type of cannabis at least once, once their initial cannabis used did not suit them, and also had guidance on how to use MC.The study started nearly 7 months prior to submitting the manuscript.These patients were contacted by phone and were asked if they wanted to participate in this study. After they gave their consent (by phone), their demographic and clinical parameters were documented, including their age, gender, indication for MC license acquisition, the current monthly amount of cannabis consumption, current THC and CBD concentrations, way of MC consumption, and MC impact on pain and sleep quality. The impact on pain was evaluated through a standard questionnaire item: “Grade the effect of your current MC consumption amount on your pain level from 0 to 100, where 0 stands for no change and 100 stands for full improvement.” As for the impact on sleep quality, it was evaluated through the following standard questionnaire item: “Grade the effect of your current MC consumption amount on the quality of your sleep from 0 to 100, where 0 stands for no change and 100 stands for full improvement or normal refreshing sleep.”A linear regression analysis using SPSS software, version 22, assessed the correlation between different parameters and the percentage of improvement of either pain or quality of sleep.This study was approved by the local Ethics Committee of the Nazareth Hospital.A total of 351 patients were identified; 339 were contacted; 10 had stopped MC consumption earlier ; and 319 provided a complete set of data. The first patient was documented in the registry nearly 6 years prior to the study.The mean pain improvement in the different groups was 57−83%, and the mean improvement in sleep quality was 71−87%.Most of the patients in the clinics that had been approved for MC treatment were fibromyalgia patients (82%), which is not surprising because fibromyalgia is a relatively common syndrome, and the number of patients with such ailment among all the patients at the rheumatology clinics is relatively high . In addiThe average improvement in sleep quality and pain level among the fibromyalgia patients in this study was relatively high: 78 and 77%, respectively, similar to the results of other studies. In a prospective study by Sagy et al. , 81.1% oIn another prospective study by Giorgi et al. , THC-ricThe leading theory behind the development of fibromyalgia is central sensitization, with dysregulation of pain perception and hyperalgesia , and theAbout 4% of the MC-licensed patients in our registry had inflammatory problems. The impact of MC on such patients' pain level was much less favorable than that on their sleep quality (57 vs. 76%). These patients (with inflammatory problems) also had higher CBD contents than the other patients. Higher doses of CBD specifically might be useful for sleep concerns .It has been shown that CBD, in particular, has an anti-inflammatory effect . Cannabiα, and PPARγ [Among the patients in this study, 9% had mechanical problems. The mean improvement in their pain level and sleep quality was also relatively high: 82 and 71%, respectively. A wide range of cannabinoid receptors was expressed on the chondrocytes of the patients with osteoarthritis of the knee. These receptors included CB1, CB2, GPR55, PPARnd PPARγ . The levnd PPARγ . Adding nd PPARγ .The highest figures of pain level and quality of sleep improvement were observed among the patients with neuropathic problems. Most of the patients had peripheral neuropathy, with pain and paraesthesia being the main distressing and annoying factors. The other patients had radicular pain, and one patient had a severe tremor. Cannabis had been shown to significantly reduce and improve neuropathic pain both in animals and humans . One stuAll the patients in this study had high THC levels with relatively low CBD concentrations. THC is known to be a powerful component for pain relief and to be more potent than CBD. The highest CBD content was seen among the patients with inflammatory arthritis. As mentioned earlier, CBD has an anti-inflammatory effect, but this effect seemed to be a weak one among the patients in this study.The monthly doses that were documented did not necessarily reflect the real amounts needed by the patients to control their symptoms. The requested dose of MC needed to be approved by the IMCA, and there was a high percentage of refusal. In general, the fibromyalgia patients reported that 1 g per day was the average dose that they needed, while among the patients with mechanical and neurologic problems, there was a demand for higher doses of MC.In the multivariate regression analysis of all the patients in this study, the THC concentration, cannabis dose, and duration of cannabis treatment were found to be significantly correlated with pain improvement, and the duration of cannabis treatment was found to be significantly correlated with sleep quality improvement. These results can be explained by the known fact that THC is an important cannabinoid for pain relief and is much more powerful than CBD , 32. TheThe lack of correlation between improvement in quality of sleep and CBD concentration could be related to the low doses of CBD relatively used by the patient . Higher The patients who stopped taking medical cannabis earlier (ten patients) were not included in the study; seven of them did so due to insufficient or lack of effect. The other two patients did so due to adverse effects; severe bitterness of the mouth due to the consumption of extract in the first; and severe diarrhea accompanied by abdominal pain in the second. The last patients stopped MC treatment due to cost issues.This study had several limitations. One of these was the lack of documentation of adverse effects and concomitant medications. The data from the literature are quite consistent with the rates of adverse effects in 25−30% of the patients using medical cannabis in this study , but the adverse effects were mostly mild to moderate, not leading to discontinuation of MC. Yet two patients on oil from the study cohort stopped MC consumption due to intolerable adverse effects.Regarding concomitant treatment, one of the requirements of the IMCA for approving MC dose rising is that the patients are still on painkillers or other specific medications for their primary disease, in order to justify MC dose raising. Thus, patients asking for MC dose rising still needed to buy their medications from the pharmacy even if these meds were ineffective and/or produced some adverse effects. Thus, concomitant treatments besides MC did not really reflect the need for them by MC-consuming patients in our study and could not reflect the real benefits that patients in our study had obtained from MC treatment.The patients in this study evidently did not represent the real-world MC treatment prescribed by authorized physicians without the need for approval by a higher authority and without restrictions on the doses to be taken by the patients.MC has a favorable effect on pain level and sleep quality among nearly the entire spectrum of resistant “chronic pain syndromes” seen or referred to rheumatology clinics, including inflammatory diseases resistant to biological treatment, although the effect of MC on synovitis was relatively mild.Cannabis should be seriously considered in every “chronic pain condition” whenever the accepted modalities of treatment are insufficient for alleviating patient's pain and sleep problems.