Background and Objectives: The pupillary pain index (PPI) allows the evaluation of intraoperative nociception by measuring pupillary reaction after a localized electrical stimulus. It was the objective of this observational cohort study to investigate the pupillary pain index (PPI) as a method to evaluate the fascia iliaca block (FIB) or adductor canal block (ACB) sensory areas during general anaesthesia in orthopaedic patients with lower-extremity joint replacement surgery. Materials and Methods: Orthopaedic patients undergoing hip or knee arthroplasty were included. After anaesthesia induction, patients received an ultrasound-guided single-shot FIB or ACB with 30 mL and 20 mL of 0.375% ropivacaine, respectively. Anaesthesia was maintained with isoflurane or propofol/remifentanil. The first PPI measurements were performed after anaesthesia induction and before block insertion, the second at the end of surgery. Pupillometry scores were evaluated in the area of the femoral or saphenous nerve (target) and C3 dermatome (control). Primary outcomes were differences between PPIs before and after peripheral block insertion as well as the relationship between PPIs and postoperative pain scores; secondary outcomes were the relationship between PPIs and opioid requirements after surgery. Results: PPI decreased significantly from the first to the second measurement . Control and target measurements did not show significant differences. A linear regression analysis showed that early postoperative pain scores could be predicted with intraoperative piritramide with improved prediction after adding PPI scores, PCA opioids and surgery type. Forty-eight-hour pain scores at rest and in movement were correlated with intraoperative piritramide and control PPI after the PNB in movement and with second-postoperative-day opioids and target PPI scores before block insertion, respectively. Conclusions: While the effect of an FIB and ACB could not be shown with PPI postoperative pain scores due to a large effect of opioids, perioperative PPI was shown to be associated with postoperative pain. These results suggest that preoperative PPI may be used to predict postoperative pain. The fascia iliaca block (FIB) and the adductor canal block (ACB) as parts of peripheral regional anaesthesia (PRA) have become standard of care in patients undergoing total hip (THR) or total knee replacement (TKR), respectively . It has Videopupillometry is a novel method which uses the registration of the pupillary response to a standardized local electrical stimulus applied to the skin area of interest . It can This prospective observational study was performed at the University of Bonn, Germany, between January and May 2019 and registered at the German clinical trials registry . Ethical approval for this study was provided by the ethics committee of the University of Bonn .Patients undergoing THR or TKR under general anaesthesia with PRA were included in this study after informed consent. Patients with recorded substance abuse, age <18 years and an ASA score >3 were excluded from the study.In the operation room, an intravenous line was inserted, and patients were connected to the ASA standard monitoring and bispectral index monitoring . Anaesthesia was induced with 0.2 mg fentanyl, 2 mg/kg propofol and 0.6 mg/kg rocuronium, followed by intubation and mechanical ventilation. For maintenance, a total intravenous anaesthesia with propofol and remifentanil or a balanced anaesthesia with isoflurane and remifentanil was used. The BIS was targeted between 40 and 60 as per standard hospital protocol. After intubation, patients received a peripheral nerve block. Patients with THR received an FIB. Most patients with TKR received an ACB although some TKR patients received an FIB to avoid interference with the surgical field.For the FIB, the fascia iliaca was localized with ultrasound at the level of the inguinal crease. A quantity of 30 mL of ropivacaine 0.375% was injected beneath the fascia iliaca usually about 3 cm lateral to the femoral artery to reach a lateral and medial spread of the local anaesthetic.For the ACB, the ultrasound transducer was positioned on the anteromedial side of the thigh so that the sartorius muscle could be seen directly above the femoral artery and proximal to the point where the artery descends through the adductor canal. Then, 20 mL of ropivacaine 0.375% was injected laterally to the artery at the location of the saphenous nerve.Patients received intraoperative analgesia with remifentanil at a rate of 0.1–0.3 µg/kg/min. At the time of fascia closure, patients received a piritramide IV bolus according to the anaesthesiologist’s judgement. In addition, all patients received 1–2 g of metamizole intraoperatively.After surgery, patients were extubated and transferred to the postanaesthesia care unit (PACU), where they were connected to a patient-controlled analgesia device (PCA). Patients were discharged from the PACU when they were fully awake, hemodynamically stable, with NRS ≤ 3.Total-knee-replacement patients received PCAs with piritramide and THR patients received PCA with a tramadol–metamizole combination. Tramadol PCA patients received continuous tramadol (10 mg/h) as well as boluses (10 mg) with a maximal 4 h dose of 90 mg, while the piritramide PCA patients could receive 2 mg boluses every 8 min with maximal 4 h dose of 30 mg. In the orthopaedic ward, patients were interviewed about their current pain experiences using the numeric rating scale (NRS) at 24 and 48 h at rest and in movement during mobilization. The doses of opioids administered via PCA  were also recorded.Electrodes of a pupillometry device  were applied on the skin area affected by regional anaesthesia (target measurement) and the C3 dermatome in the supraclavicular fossa (control measurement). Target site for the ACB was the dermatome of the saphenous nerve distal to the injection site, and for the FIB, the dermatome of the femoral nerve 10 cm distal to the inguinal crease. The target and the control PPI scores were assessed twice, first after anaesthesia induction before remifentanil was started and before block insertion, and second, at the time of skin suture.A handheld infrared camera registered the pupil size automatically. Once the measurement process was started, an increasing electric current of up to 60 mA was applied to the electrodes in 10 mA steps. From the pupillary reaction, the PPI score was automatically generated and recorded.Measurement bias: PPI measurements were performed by the same researcher and did not affect the decisions of the staff. NRS scores measurements and recordings of the opioid doses from PCA devices were performed by nursing staff as per routine protocol. Selection bias was decreased by enrolling study participants consecutively. General anaesthesia with the use of opioids can represent a potential confounder which cannot be ruled out completely. The positioning of the control site electrodes may have influenced the control measurements. In addition, unknown potential factors could have affected the findings presented here.Based on a previous pilot study , it was -The differences between PPIs before and after peripheral block insertion.-The relationship between PPIs and NRS scales .The primary outcomes were:The secondary outcome was the association between PPIs and opioid consumption from PCA devices  in morphine equivalent.A statistical analysis was performed using SPSSv26  and MATLAB R2020a  software. As PPI is an ordinal scale, nonparametric tests were used.Morphine equivalents were calculated from PCA opioid doses as follows: piritramide PCA—1 mg of piritramide = 0.7 mg of morphine. Tramadol–metamizole PCA—1 mg of tramadol = 0.1 mg of morphine; metamizole was not taken into account .p < 0.05 (two-sided).Continuous variables are presented as mean ± SD. The Wilcoxon signed rank test was used to compare paired samples, the Mann–Whitney test was used to compare independent samples. A Spearman test was used to assess the correlation between target PPI after block and postoperative pain scores. Statistical significance was defined as p value < 0.2 and the models with the best adjusted R-squared value were reported. The dependent variable was the postoperative pain score . The independent variables were PPI scores from the first and second measurements in the target area and the control area, as well as surgery type (THR or TKR), PCA type (tramadol or piritramide) and perioperative opioids. For the NRS PACU, intraoperative piritramide was included as a covariate, and for the NRS 24 h and the NRS 48 h, intraoperative piritramide and total opioids on the first and second postoperative days were included, respectively. Considering the possible multicollinearity between the dependent variables, variance inflation factors (VIF) were also reported. Due to potential differences between surgery groups, separate regression models were also calculated for each group (THR and TKR). Additionally, simple linear regression analyses were performed for each dependent and independent variable for the entire study cohort, as well as for each group.To investigate whether PPI scores could predict postoperative pain levels, multiple linear regression models were constructed using a stepwise selection of p = 0.05, Forty-four (44) patients initially participated in the study, and 35 patients were included in the final analysis. The flowchart of patient inclusion is shown in Data are presented as number (%) and mean ± standard deviation; for age and body mass index—mean (range). The remifentanil dose ratio was calculated as a total remifentanil dose in mcg/surgery time in minutes. PCA—patient-controlled analgesia; NRS—numeric rating scale; PACU—postanaesthesia care unit; MED—morphine equivalent dose. For piritramide, MED was calculated as 1 mg of piritramide = 0.7 mg of morphine; for tramadol, 10 mg of tramadol = 1 mg of morphine.p < 0.001) and the C3 dermatome area . The comparison between control and target measurements did not show significant differences (p = 0.046), as well as the NRS 48 h in movement . Other pain scores did not show significance in terms of PPI .PPI scores after the block were significantly lower than before the block both in the FIB and ACB sensory areas ) could be predicted with intraoperative piritramide . Adding 2 = 0.346, p = 0.03). The NRS 24 h in movement correlated with the same predictors as well as the first-postoperative-day opioids . The NRS 48 h in movement showed relationships with intraoperative piritramide and PPI scores . For the TKR surgery, the NRS 24 h in movement was associated with intraoperative piritramide . The NRS 48 h at rest connected to intraoperative piritramide and second-postoperative-day opioids ; The NRS 48 h in movement correlated with the same predictors as well as with the PPI scores . The complete information concerning the regression analysis and prediction models for each group can be found in After splitting the models by surgery type, we could not predict the NRS PACU with the included independent variables. For the THR surgery, the NRS 24 h at rest was associated with intraoperative piritramide and the target PPI before PNB (adjusted RNo correlation could be observed between the PPIs and perioperative opioid consumption .Postoperative pain after joint arthroplasty is an important challenge for postoperative outcome. Postoperative mobilization can be facilitated via the use of peripheral regional anaesthesia, which can ultimately influence operative results. With the PPI, we aimed to assess the effectiveness of peripheral nerve blocks in THA and TKA surgeries. Although our data did not support an effect of the peripheral nerve block on PPI values, PPI values were associated with postoperative pain values.PPI values alone were not associated with postoperative opioid consumption. However, the comparison between the THR and TKR groups revealed an increased opioid consumption in the THR group. It must be noted at the same time that all THR patients received an FIB while TKR patients received both an ACB and an FIB. While one might expect an increased opioid consumption in the TKR group, the opposite was the case ,11. We aThe observed differences between PPI1 and PPI2 suggest that PPI can be considerably influenced by opioid administration. This finding is in line with previous reports from Sabourdin et al., who investigated the PPI during general anaesthesia with and without opioids . In our Although the effect of the peripheral nerve block was not reflected in the PPI, PPI1 at the target site was related to postoperative pain on the second postoperative day in movement. Due to the active nature of the PPI, the method seems to be especially useful in predicting pain in postoperative mobilization. These results are in line with previous findings that reported the usefulness of a preoperative heat stimulus to predict postoperative pain in knee surgery . A lineaThere are several limitations inherent in this study. TKA and THA patients represent different groups of patients. Additionally, in our cohort the group sizes receiving an ACB and FIB were different, and different nerve blocks were applied in the TKA group. A postoperative management with a tramadol mixture in THA patients as opposed to TKA patients with piritramide PCAs adds to the difficulty of comparing the two groups. Furthermore, we presented a relatively small cohort of patients with a relatively short follow-up period and therefore, results are of preliminary nature and should be interpreted in this context. We performed regional anaesthesia after the induction of general anaesthesia, although this is not ubiquitously practiced. Therefore, the results presented here may not be applicable in all circumstances.Our results do not support the use of the PPI for the evaluation of an FIB and ACB when used in conjunction with opioids. However, the PPI may have a role in the prediction of postoperative pain. We suggest that the degree of postoperative pain may be predetermined even before surgical skin incision.


This study aimed to evaluate the value of fat-suppressed T2-weighted imaging (FS-T2WI) for predicting short-term pain relief after polidocanol sclerotherapy for painful venous malformations (VMs) in the extremities.This retrospective study included patients with painful VMs in the extremities between October 2014 and September 2021, had their first sclerotherapy without history of surgical therapy, and underwent magnetic resonance imaging before sclerotherapy. Pain relief was assessed 2 months after 3% polidocanol sclerotherapy and was categorized as follows: progression, no change, partial relief, or free of pain. The associations between pain relief and imaging features on FS-T2WI were analyzed.The study included 51 patients. The no change, partial relief, and free of pain groups included 6 (11.8%), 25 (49.0%), and 20 (39.2%) patients, respectively. No patient experienced progressive pain. The lesion diameter was ≤ 50 mm in 13 (65.0%) patients in the free of pain group, whereas it was > 50 mm in all patients in the no change group (p = 0.019). The lesions showed well-defined margin in 15 (75.0%) patients in the free of pain group, whereas they showed ill-defined margin in 5 (83.3%) patients in the no change group (p = 0.034). The most common morphological type was cavitary in the free of pain group (14 [70.0%] patients), whereas there was no patient with cavitary type lesion in the no change group (p = 0.003). Drainage vein was demonstrated in 6 (100%), 22 (88.0%), and 11 (55.0%) patients in the no change, partial relief, and free of pain group, respectively (p = 0.011).A lesion size of 50 mm or less, a well-defined margin, a cavitary type, and no drainage vein on FS-T2WI were significant features for predicting short-term pain relief after polidocanol sclerotherapy for painful VMs in the extremities. Venous malformations (VMs) are part of the spectrum of vascular malformations and are the most common vascular malformations. VMs are characterized by slow blood flow and an abnormal venous network owing to errors in endothelial cell morphogenesis. They tend to grow, often painfully, in proportion to the growth of the patient and often enlarge during puberty and pregnancy . VMs in Magnetic resonance imaging (MRI) is excellent for defining the extension of VMs and assessing their relationship with adjacent structures. In particular, fat-suppressed T2-weighted imaging (FS-T2WI) shows VMs and the veins continuous with VMs as structures with high signal intensity owing to stagnant or slow blood flow in abnormally dilated venous spaces –4.Generally, symptomatic VMs are treated using multiple modalities, including surgery, sclerotherapy, and laser therapy, as well as compression therapy and medications, such as low-dose aspirin . The emeThere are several reports on the relationship between clinical outcomes after sclerotherapy and imaging features based on MRI , 9–15. HApproval for this retrospective study was obtained from our institutional review boards. The requirement for informed consent was waived by the ethics committee owing to the retrospective nature of the study.Patients were included if they presented with painful VMs in the extremities between October 2014 and September 2021 at our hospital, had their first sclerotherapy session without history of surgical therapy, and underwent baseline MRI including FS-T2WI before sclerotherapy.A total of 67 consecutive patients were identified. Among them, 16 patients were excluded for the following reasons: VMs were part of Klippel–Trenaunay syndrome (4 patients), MRI was performed more than 12 months before sclerotherapy (10 patients), and consultation history was absent after sclerotherapy (2 patients)  to 3% polidocanol  to be visible during injection and to avoid leaking into the extra-venous surrounding tissue due to unstable punctured needle. The sclerosing foam was produced based on Tessari’s method, agitating 3% polidocanol, air, and iodixanol in a ratio of 2:4:1 by repeated transfer between two syringes . We usedThe 3% polidocanol foam was injected under digital subtraction angiography (DSA) guidance until a sufficient amount of the form accumulated in the VMs. If a drainage vein appeared before sclerosing foam was pooled in the VMs, a tourniquet was applied at the proximal portion of the VMs on the extremity, or the drainage vein was pressed with fingers. The amount of polidocanol foam was determined according to the estimated volume of the VMs on DPV.Data were collected retrospectively using electronic patient records and a picture archiving and communication system (PACS). Clinical success was decided by two attending interventional radiologists by means of consensus, using electronic patient records. Pain was assessed at 2 months after sclerotherapy because swelling and pain can increase in the VM region for some time after the procedure. Pain outcomes were categorized as follows: progression, no change, partial relief, or free of pain. Pain Progression was defined as worsening of pain compared to that before sclerotherapy. No change in pain was defined as neither worsening nor improvement of pain compared to that before treatment. Free of pain was defined as the complete disappearance of pain. Patients who had neither no change in pain nor complete disappearance of pain were considered to have partial relief of pain.All examinations were performed using a 3.0-T MRI system  with adjustments of the coils, field of view, and matrix, depending on the lesion size, location, and depth. All MRI scans were performed within 12 months before sclerotherapy. MRI protocols had to include at least one T1-weighted fast spin-echo imaging and two planes  of T2-weighted fast spin-echo imaging with fat-suppression techniques (CHESS or Dixon). The ranges of repetition time and echo time were 500–700 ms and 10–15 ms for T1-weighted fast spin-echo imaging, and were 4000–5200 ms and 40–90 ms for T2-weighted fast spin-echo imaging, respectively. Section thickness ranged from 3 to 5 mm.Two board-certified radiologists independently evaluated the imaging findings of VMs on FS-T2WI. The radiologists were blinded to both the clinical information and outcomes after sclerotherapy. After each radiologist interpreted the images, they discussed any differences in their evaluations to reach a consensus. All VMs were evaluated for the longest lesion diameter, margin definition, morphological type, presence of a drainage vein, presence of a thrombus or phlebolith, and presence of a fluid–fluid level on FS-T2WI. The margin definition was categorized into well-defined and ill-defined. The morphological types of VMs were classified into three patterns—cavitary, spongy, and dysmorphic pattern—based on FS-T2WI. VMs with or without a few septa were considered to have a cavitary pattern, those with small honeycomb cavities were considered to have a spongy pattern, and those with dysmorphic veins were considered to have a dysmorphic pattern.Continuous data are presented as means with standard deviation (SD) or as medians with ranges or interquartile ranges (IQRs). Categorical data are presented as counts and percentages. The Kruskal–Wallis test with the Steel–Dwass test was used to compare pain outcome groups in terms of age and the longest lesion diameter. The association between pain outcome and age, sex, location, depth, lesion diameter category (≤ 50 mm or > 50 mm), and features on FS-T2WI  were analyzed using the Fisher exact test.p value < 0.05 was considered significant. All statistical analyses were performed using JMP version 16.0.0 .The interobserver variation in the MRI interpretation data was analyzed using the kappa statistic  for the The study included 51 patients  with VMs. The amount of 3% polidocanol ranged from 35 to 180 mg . Among the 51 patients, 40 (78.0%) experienced pain at the injection site after 3% polidocanol sclerotherapy. This early complication was self-limited, and it resolved with conservative approaches. No patient developed skin injury, soft tissue necrosis, local infection, or sensory loss.p = 0.36), sex (p = 0.77), location (p = 0.29), or depth (p = 0.25). On the other hand, the longest lesion diameter significantly differed among the three groups (p = 0.038). The longest lesion diameter was significantly larger in the no change group than in the free of pain group (p = 0.006). The longest lesion diameter was ≤ 50 mm in 13 (65.0%) patients in the free of pain group, whereas it was > 50 mm in all patients in the no change group (p = 0.019) , 25 (49.0%), and 20 (39.2%) patients, respectively. Pain outcomes were not significantly different by age  for margin definition, morphological type, presence of a drainage vein, and presence of a fluid–fluid level, and was moderate (κ = 0.55) for presence of a thrombus or phlebolith (Table –0.77 forTable p = 0.034). The lesion showed well-defined margin in 15 (75.0%) patients in the free of pain group, whereas it showed ill-defined margin in 5 (83.3%) patients in the no change group. Cases of VMs with well- and ill-defined margins are shown in Figs. VMs had well-defined margin in 30 out of 51 patients (58.8%). The pain outcome was significantly different by the margin definition (p = 0.003). The most common type was cavitary in the free of pain group (14 [70.0%] patients), whereas there was no patient with cavitary type lesion in the no changes group.The most common morphological type was the cavitary type (52.9%), followed by the spongy type (31.4%) and dysmorphic type (15.7%). The pain outcome was significantly different by the morphological type (p = 0.011). Drainage vein was demonstrated in 6 (100%), 22 (88.0%), and 11 (55.0%) patients in the no change, partial relief, and free of pain group, respectively.A drainage vein was present in 39 out of 51 patients (76.5%) Figs. . The paip = 0.79), or the presence of a fluid–fluid level (p = 0.44).There was no significant difference in the pain outcome according to the presence of a thrombus or phlebolith  than those greater than 50 mm. VMs with well-defined margins on FS-T2WI tended to more frequently be associated with the complete disappearance of pain after sclerotherapy. These results are consistent with the findings of previous reports , 15, 18.With regard to the morphological type, the cavitary type tended to show a preferable response, whereas the spongy type tended to show a limited to poor response. We speculate that the spongy type VMs were divided by the septa into the small parts which had sparse communication with each other, and the sclerosant was less likely to spread throughout the lesion. Dubois et al. classified VMs into cavitary, spongy, and dysmorphic types based on DPV and found that the results with sclerotherapy were better for the cavitary and dysmorphic types than the spongy type . AlthougRegarding the drainage vein, pain relief tended to be associated with the absence of a drainage vein on FS-T2WI, whereas no pain relief tended to be associated with the presence of a drainage vein. Yun et al. evaluated the relationship between the drainage vein and treatment efficacy using DPV and reported that no or delayed visualization of the drainage vein was associated with a preferable response to percutaneous sclerotherapy . Mimura There have been reports on the prediction of the therapeutic effects of sclerotherapy for VMs using dynamic contrast-enhanced MRI , 19. XiaThis study has three major limitations. First, because this was a retrospective study, semi-quantitative assessment using the Visual Analog Scale (VAS) was not available. The evaluation of pain after sclerotherapy had to rely solely on information available in the electronic medical records. Second, we assessed degree of pain relief at 2 months after sclerotherapy. That is, only short-term pain improvement of VMs was evaluated, but their effectiveness in the long-term was not demonstrated in this study. Third, we focused on pain relief and did not consider functional limitations and cosmetic satisfaction in this study. Nakahara et al. evaluated the efficacy of percutaneous sclerotherapy for VMs in pediatric patients, using overall satisfaction, including not only pain but also swelling, functional limitations, and cosmetic disfigurement, assessed with a self-assessment questionnaire. They concluded that sclerotherapy is effective for relieving symptoms and many of the patients were satisfied with the outcomes . FurtherIn conclusion, a lesion size of 50 mm or less, a well-defined margin, a cavitary type, and no drainage vein on FS-T2WI before sclerotherapy were significant features in predicting short-term pain relief after polidocanol sclerotherapy for painful VMs in the extremities.


Vulvar Functional Status Questionnaire (VQ) was used for the evaluation of patient's chronic pelvic pain and muscle hypertone improvements. The interstitial cystitis was assessed by the Leary–Sant symptom and problem indexes (ICSI and ICPI). In this study, the scores resulting from the sum of the two indexes were evaluated as OSS (ICSI + ICPI). p  <  0.005) from the second treatment up to the sixth one. In 6 patients affected by interstitial cystitis, the mean score of OSS was significantly lower than the controls (p  <  0.005) from the second treatment up to 2 months follow-up after the last treatment session. No side effects were observed.  Women with chronic pelvic pain and muscle hypertone showed VQ mean values significantly lower than the controls ( Based on these results, this technology may successfully manage muscle hypertonicity condition, the chronic pelvic pain, and interstitial cystitis. Pelvic floor tension myalgia (PFTM) is a type of pelvic floor dysfunction related to increased activity or hypertonicity of pelvic floor muscles that leads to chronic pelvic pain or miofascial syndrome . It is uThe exact cause of pelvic floor tension myalgia is not known, but multiple variables may contribute to its development, such as nerve damage, irritable bowel syndrome, endometriosis, genitourinary inflammation, interstitial cystitis, poor posture, aging, obesity, history of sexual abuse, pudendal nerve entrapment, trauma, reaction to pelvic organ disease, postsurgical scarring, rectal disorders, central pain sensitization, and psychological factors. Pelvic floor muscle spasm is thought to be a major cause of PFTM. Recurrent urinary tract infections (rUTIs), in particular interstitial cystitis symptoms without infection, are common in women and frequently present in general practice , 7.Interstitial cystitis, also known as painful bladder syndrome, can cause lower abdominal pain/discomfort, dyspareunia, and pain in any lower spinal nerve distribution. Additional bladder-related symptoms, such as frequency, urgency, or nocturia, are experienced by patients with this condition. It can affect people of all ages and should be considered for people who have other chronic pain conditions such as fibromyalgia, irritable bowel syndrome, chronic fatigue, or chronic pelvic pain .Interstitial cystitis/painful bladder syndrome is frequently associated with high-tone pelvic floor dysfunction. Because of their syndromic nature and amorphous definitions, these conditions are common in gynaecological patients presenting with chronic pelvic pain and are frequently misdiagnosed. Clinicians should be cautious of these processes in patients who suffer from recurrent urinary tract infection symptoms or chronic pelvic pain . The twoGenerally, a gynaecologist with great expertise follows a therapeutic path aimed at reducing the three triggering causes of pelvic chronic pain condition: reduction of local inflammation as not to further fuel the disease, regularization of nerve transmission to decrease pain, and relaxation of contracted muscles .Treatment for PFTM is frequently difficult, with numerous treatments showing limited success. The literature on PFTM treatment is quite varied. Massage, medication, high-voltage electro-galvanic stimulation (HVGS), biofeedback, short-wave diathermy, botulin toxin injections, relaxation therapies, cognitive behavioral therapy, ultrasound, sit baths, posture training, hydrotherapy, strengthening exercises, and transcutaneous electrical nerve stimulation (TENS) units appear to be most beneficial in these patients. The outcomes of these treatments varied, and there is not much evidence to support or refute their efficacy . AnalgesMagnetic stimulation has been explored as an alternative to electrical stimulation recently for urological diseases, clinical neuro-diagnostic applications, and pelvic floor muscle strengthening, pain, and hypertonia to provide safe and noninvasive treatment for chronic pelvic pain syndrome –18.Recently, Biondo and Colleagues  observedBased on these considerations, our study provided insight into the assessment of the effectiveness and safety of a novel device that uses top flat magnetic stimulation to treat women with interstitial cystitis and chronic pelvic pain.A total of 12 Caucasian women with a mean age of 30.66 (±14.66) were enrolled for this study see .All (12/12) patients presented with chronic pelvic pain such as dyspareunia, pain during intercourse, and vestibulodynia, 4/12 patients presented muscle hypertone and 6/12 patients presented with interstitial cystitis (with negative urinoculture).To perform a correct and accurate diagnosis of chronic pelvic pain, we have excluded all the pathologies which could be responsible for the same type of painful symptoms; exclusion criteria included the presence of patients with menopause state, pelvic organ prolapses, genital infections, menstruation, malignant tumors, severe neurological diseases, pregnancy, obesity, and persons with pacemakers or metal implants. Inclusion criteria included patients affected by chronic pelvic pain and pelvic floor hypertonicity.The diagnosis of hypertonic pelvic floor is performed in all patients by an experienced gynaecologist with a manual assessment of the pelvic floor muscles and a swab test.This study was conducted in accordance with the Good Practice Guideline and the Declaration of Helsinki and informed consent was obtained from all patients.A noninvasive electromagnetic therapeutic device  with a main unit and a chair applicator was used during the procedures. The coil of the chair applicator, which is located in the center of the seat, is intended for therapy of the deep pelvic floor area. The patient is seated on the chair with their perineum on the center of the seat, which helps them feel the stimulation of their pelvic floor and sphincter muscles during stimulation therapy. In order to stimulate the pelvic area, DR. ARNOLD can produce an electromagnetic field with a homogenous profile (TOP FMS-TOP Flat Magnetic Stimulation). Gynaecologists initially set and adjusted the patient's position before each session to ensure an appropriate level of stimulation and achieve a uniform distribution of muscle involvement. The beneficial effect of the subject device is due to a greater uniformity of magnetic field distribution over a larger area, which allows for greater recruitment of muscle fibers without generating areas that differ in stimulation intensity. The device's change in magnetic fields transmits the current into nerves which send signals to the muscles in order to contract and release them. The crucial thing is the positioning of the patient (patient's pelvic floor muscle (PFM)) in the chair. Patients PFM should be positioned in the center of the magnetic field for optimal  effect. First and foremost, the patient's comfort throughout the lengthy treatment session is ensured. Second, it makes it possible to center the electromagnetic field on the patient's perineum. With the study device, the patient can be positioned precisely so that his legs are in the right positions by adjusting the seat height prior the treatment. The legs of the patient are positioned perpendicularly, ensuring the thighs are parallel to the floor with the feet flat on the ground. At the knee, patients ought to create an angle of 90 degrees or slightly higher. The subject system is equipped with protocols for reducing hypertonicity that use low-frequency stimulations (around 10 Hz) in accordance with the treatment's goals.The DR ARNOLD system was applied for a total of 6 treatments on all patients. Sessions were conducted twice weekly for three consecutive weeks; depending on the patient's muscular condition, each session lasted 28 minutes. The overtone/pain protocol (muscle work aimed at muscle inhibition and reduction of pain (hyperactivity and hypertone)) was selected after the first two minutes of warm-up for all patients. Data were collected at baseline, after each treatment session up to 6 treatments, and after 2 months of follow-up after the last treatment session. In all patients, chronic pelvic pain was evaluated using the Vulvar Functional Status Questionnaire (VQ) .The interstitial cystitis was assessed by the Leary-Sant symptom and problem indexes (ICSI and ICPI). In this study, the scores resulting from the sum of the two indexes were evaluated as OSS (ICSI + ICPI) , 22.Possible side effects and adverse events such as muscular pain, temporary muscle spasm, temporary joint/tendon pain, or local erythema/skin redness were evaluated during all treatment periods.t-test. A p  <  0.05 is considered to be significant.SPSS  was used for all statistical analyses. Descriptive statistical analysis (means and ±SDs) was performed using the Student's p  < 0.005) from the second treatment up to the last one. For all patients evaluated, the mean score of Vulvar Functional Status Questionnaire (VQ) decreased from 13.7 (±4.47) at baseline to 12.5 (±5.25) after 1 treatment session, significantly decreased from 13.7 (±4.47) at baseline to 8.5 (±4.74) after 2 treatment sessions, to 6.3 (±4.24) after 3 treatment sessions, to 4.3 (±3.56) after 4 treatment sessions, and to 3.1 (±3.67) after 5 treatment sessions and to 2.86 (±4.49) after 6 treatment sessions, showing an improvement in chronic pelvic pain and in the four patients with hypertonicity symptoms .Women with chronic pelvic pain alone or in association with muscle hypertonicity showed VQ mean values significantly lower than the controls  at baseline to 17.2  after 1 treatment session, significantly decreases from 23.3  at baseline to 8.5 (±6.16) after 2 treatment sessions, to 5.5 (±4.85) after 3 treatment sessions, to 0.5 (±0.55) after 4 treatment sessions, to 0.2 (±0.45) after 5 treatment sessions, to 0.25 (±0.5) after 6 treatment sessions, and to 2.6 (±2.52) at 2 months follow-up after the last treatment session . No sideThe pelvic floor muscles are deeply stimulated by magnetic stimulation technology, which restores neuromuscular control . Muscle p  <  0.005) from the second treatment up to the last one.Women with chronic pelvic pain alone or in association with muscle hypertonicity showed VQ mean values significantly lower than the controls . However, there are already published studies  in whichIn addition, interstitial cystitis was also treated with success as assessed by OSS questionnaire which reported promising results. In addition, when compared to the assortment of devices available for pelvic floor restoration, the subject device offers additional significant benefits. It is a noninvasive device first and foremost because no probe is inserted into the vaginal channel during muscle stimulation. As a result, patients can remain fully clothed in a supportive and ergonomic chair and resume their daily activities right away after sessions thanks to the consistent emission of energy that is gradually delivered. Finally, the DR. ARNOLD system can be viewed as an “educator” system, since it allows the patient to feel the relaxation of the muscles that are being treated, giving them more autonomy and awareness to decide when to repeat the next treatment session.In addition, this technology can be utilized in conjunction with other pharmacological or physical techniques . Our lonStudy limitations are represented by a small patients' sample, a short follow-up, and the lack of a control group.Our investigation reveals that this technology could represent a promising approach for the treatment of chronic pelvic pain as well as muscle hypertonicity condition and interstitial cystitis. Based on 2-month follow-up data, it seems that the effect is short-lasting, but a limited number of patients were evaluated at this time. In order to monitor the device's long-term effects, additional studies with follow-ups of up to 4 or 6 months will be required.


Each group received three sessions, separated by 4 days, of either DN or MT. Outcomes were assessed according to pain intensity , AMMO (cm), disability (Neck Disability Index), and pressure–pain threshold (PPT)  from the active myofascial trigger points. In both groups, pain and neck disability were significantly lower at the end of treatment compared with those measured at baseline , but not were not lower after the first session, without differences between the groups. AMMO was significantly higher after the first session  and at the end of treatment in both groups  compared with the baseline measurements. Finally, PPT results for the masseter and pterygoid muscles were significantly higher at the end of treatment in both groups , but not after the first session. The assessed therapies, DN and MT, are equally effective in improving pain, AMMO, cervical disability, and PPT in the muscles directly involved in the temporomandibular joint biomechanics of patients with myofascial TMDs.Dry needling (DN) is an invasive physiotherapy technique employed for reducing myofascial pain. To compare the effectiveness of dry needling (DN) versus manual therapy (MT) in improving pain, active maximal mouth opening (AMMO) and cervical disability in patients with myofascial pain from temporomandibular disorders (TMDs) were investigated against these treatments. A single-blind, randomized controlled trial was carried out. Individuals ( The temporomandibular joint (TMJ) is shaped like a bicondylar diarthrosis, showing a double connection, with the temporal bone and the mandible, and is one of the most complex joints in the human body . TemporoThe etiology of TMD is considered multifactorial, and includes genetic and physical predisposition, psycho-emotional factors, neck disorders, trauma, and daily habits such as chewing gum or clenching teeth . These tIn 2013, the International Research Diagnostic Criteria for Temporomandibular Dysfunction Consortium Network published an updated classification structure for TMDs. The most commonly associated syndromes include myofascial pain disorder, disk derangement disorders, osteoarthritis, and autoimmune disorders ,12. MyofCurrently, there are multiple therapeutic approaches to reduce the symptoms associated with TMDs. The most conservative approaches include pharmacotherapy, dental splints, and traditional physiotherapy; these treatments are minimally aggressive and achieve positive clinical effects. Firstly, pharmacotherapy is indicated to reduce pain and inflammation in the area; however, the indicated substances pose significant risks for patients, such as gastrointestinal or kidney problems , if takeAmong the more invasive physiotherapy techniques, dry needling stands out, and is considered minimally invasive. The application of dry needling in myofascial trigger points consists of introducing a low-caliber needle, without additional substances, into the active trigger points to produce a deactivation . There aThe aim of this study was to compare the effectiveness of manual therapy versus dry needling therapy in terms of perceived pain, mouth opening movement, the degree of cervical disability, and the pressure–pain threshold (PPT) of active myofascial trigger points (MTrPs) in patients with temporomandibular joint disorders.clinicaltrials.gov (NCT04469088) and was conducted according to the recommendations of the Consolidated Standards of Reporting Trials (CONSORT) statement for randomized controlled trials by the World Health Organization and the International Committee of Medical Journal Editors (ICMJE). Ethical approval was obtained from the Ethical Committee of the University of Jaén (JUN.20/4.PRY), and the study was conducted according to the Declaration of Helsinki. The randomized controlled trial was carried out between June 2021 and March 2022.This single-blind randomized controlled trial was registered at Participants between 18 and 65 years old with TMDs were recruited from the Miophys Physiotherapy and Rehabilitation Clinic  using convenience sampling. Participants had to meet at least two of the following inclusion criteria: (1) pain on palpation of the MTrP of the right or left masseter, lateral pterygoid, and sternocleidomastoid muscles (minimum 3 active trigger points); (2) pain in the temporomandibular joint; (3) limited mouth opening; and (4) clicking of the temporomandibular joint. We considered the following exclusion criteria: fibromyalgia; orthodontia; systemic disease, syndrome, or pathology with possible joint repercussions (including bruxism); patients undergoing treatment with anti-inflammatory drugs; jaw fracture; mandibular surgery; non-collaborative patients; and patients with phobias of needles. After the inclusion criteria were applied, all participants were classified according to original Research Diagnostic Criteria for Temporomandibular Disorders (RDCs/TMDs) .All participants provided written informed consent before enrollment. At the beginning of the study, they were randomly allocated into two intervention groups  using the random allocation functions of the Epidat software version 3.1 .Subjects received 3 sessions of dry needling or manual therapy, separated by 4 days. An expert physiotherapist carried out the interventions in both groups.This treatment consisted of puncturing the possible active MTrP of the right or left masseter, lateral pterygoid, and sternocleidomastoid muscles. MTrPs are defined as hypersensitive spots within taut bands of skeletal muscle, which are painful upon compression and trigger characteristic referred pain. MTrPs are classified as active when they cause spontaneous pain and latent when they only provoke pain when stimulated.Patients in this group received dry needling in at least 1 active trigger point and in a maximum of 6. Sterile needles, 0.26 mm in diameter by 40 mm in length, guided with a plastic cannula of the brand Ener-qi, were used. The area was cleaned with alcohol and deep puncturing of the myofascial trigger point was performed, triggering local spasm responses. The needle was moved up and down through the muscle following the technique described by Hong . After tThis treatment consisted of the application of the neuromuscular technique to the right and left masseter A and steSociodemographic information (age and gender) was collected from each patient. The main study variables were pain, active maximal mouth opening (AMMO), cervical disability, and PPT of possible active MTrPs . All variables, with the exception of disability, were assessed at baseline before treatment (T0 assessment), one hour after the first session (T1 assessment) to study the immediate effect, and two weeks after completing the treatment (T2 assessment) so that possible post-session effects could be avoided. Assessments were performed by a physiotherapist with more than 10 years of experience in the field and different from the one who performed the interventions.The Numeric Pain Rating Scale (NPRS) was used to assess the intensity of temporomandibular pain in patients . The NPRThe range of maximal mouth opening was assessed by measuring the distance (in cm) between the maxillary and mandibular incisal edges of the incisor teeth, using a validated ruler in centimeters .Neck disability was measured using the Spanish version of the Neck Disability Index (NDI) questionnaire . The NDIwww.wagnerinstruments.com, accessed on 5 December 2022). This algometer is a portable, low-cost digital force gauge, and it is commercially available as a mechanical nociceptive threshold testing device that has been validated for use in various species [2. Once the active MTrP was located within the taut band, pressure was exerted perpendicular to the muscle plane and on the active myofascial trigger points through the support surface of the device. The pressure was increased by 1 kg per second. When the pressure became painful, the individual raised their hand to warn us.The PPT in each active MTrP was measured with pressure algometry using the Wagner Force Ten™ FDX digital algometer  was used as an estimator of the size of the main effects and interactions between the ANOVAs, for which a value between 0.2 and 0.49 indicated a small effect size, a value between 0.5 and 0.79 a medium effect size, and a value > 0.8 indicated a large effect [Statistical analyses were performed using the statistical package SPSS 21.00  by a blinded statistical physiotherapist. Mean and standard deviation were included in the data description in continuous variables, and frequencies and percentages in categorical variables. To study the homogeneity of the groups at the start of the intervention, we used the one-way ANOVA for quantitative variables and the Chi-squared test for categorical variables. For the differences between groups in terms of pain intensity, maximal mouth opening, and PPT in each muscle, a 2-by-3 mixed ANOVA was conducted with time  as the within-subject factor and group  as the between-subject factor. For the differences between groups in neck disability, a 2-by-2 mixed model ANOVA was conducted with time (baseline and post-treatment) as the within-subject factor and group as the between-subject factor. Post hoc pairwise comparisons were analyzed using the Student’s e effect . Signifin = 36 with myofascial pain and n = 14 with myofascial pain and limited opening). There were no statistically significant differences between the two groups at baseline in terms of age, gender, or outcome variables. The final sample was composed of 50 participants who met the inclusion criteria . Twenty-p < 0.001; ηp2 = 0.627), with a medium effect size value, but with no significant difference between groups . There was a non-significant time-by-group interaction . Post hoc comparisons are presented in The 2-by-3 mixed model ANOVA for pain intensity revealed a significant main effect for time , close to a medium effect size value, but with no significant differences between groups . There was a non-significant time-by-group interaction . The post hoc comparisons are presented in The 2-by-3 mixed model ANOVA for active maximal mouth opening revealed a significant main effect for time , with a medium effect size value, but with no significant differences between groups . There was a non-significant time-by-group interaction . Post hoc comparisons are presented in The 2-by-2 mixed model ANOVA for cervical disability revealed a significant main effect for time , with a small effect size value, but with no significant effect for group . There was a non-significant time-by-group interaction . There was an increase in the pressure–pain threshold for this muscle, but without differences between groups. More specifically, the PPT results were significantly higher at the end of treatment compared with those at the baseline, but not after the first session.p < 0.001; ηp2 = 0.411), with a small effect size value, but no significant effect for group . There was a non-significant time-by-group interaction . PPT results for this muscle were significantly higher at the end of the treatment compared with those at the baseline, but not after the first session, and without differences between groups.The repeated measures ANOVA model test (two groups × three times) for PPT in the left masseter showed a significant main effect for time , with a small effect size value, but no significant effect for group . There was a non-significant time-by-group interaction . There was an increase in the pressure–pain threshold for this muscle, but without differences between groups. More specifically, the PPT results were significantly higher at the end of treatment compared with those at the baseline, but not after the first session.The repeated measures ANOVA model test (two groups × three times) for PPT in the right lateral pterygoid showed a significant main effect for time , but no significant effect for group . There was a non-significant time-by-group interaction . The PPT results for this muscle were significantly higher at the end of treatment compared with those at the baseline, but not after the first session.The repeated measures ANOVA model test (two groups × three times) for PPT in the left lateral pterygoid showed a significant main effect for time  in either group . There was a non-significant time-by-group interaction .The repeated measures ANOVA model test (two groups × three times) for PPT in the right sternocleidomastoid showed no significant main effect for time  in both groups . There was a non-significant time-by-group interaction .The repeated measures ANOVA model test (two groups × three times) for PPT in the left sternocleidomastoid showed a non-significant main effect for time , dry needling and manual therapy both proved effective in reducing pain and associated cervical disability, as well as improving active mouth opening ROM and increasing PPT in the active MTrPs of masseters and lateral pterygoids muscles.Previous reviews have shown that both the classical physiotherapy approach and dry needling can be effective in reducing the signs and symptoms of TMDs ,27,28. HRegarding the evaluation of pain intensity (assessed with the NPRS), none of the groups showed a post-session reduction . However, at the end of the full treatment (T2 assessment), there were clinically relevant (medium effect) and statistically significant reductions in pain in both groups, although no statistically significant differences were found between the groups. These results present great clinical relevance, since both therapies are effective in minimizing pain intensity, exceeding the minimum clinically important difference (MCID) value for the NPRS in patients with TMDs (between 1.5 and 3.2 points) . Thus, dWe assessed the effects of both therapies on the PPT of the right and left masseter, lateral pterygoid, and sternocleidomastoid muscles, with the following findings at the end of the therapy: After the full treatment, both dry needling and manual therapy demonstrated effectiveness in reducing pain sensitivity, although no effect was reported on the sternocleidomastoid muscles. Our findings did not show statistically significant differences between therapies after the full treatment, so we can suggest that both therapies, separately, are effective. These findings show that dry needling is an effective therapy for reducing the mechanosensitivity of pain in the masseter and lateral pterygoid muscles, after the end of the intervention. Our findings regarding the effect of dry needling in the masseter muscle are in line with previous studies. Fernández-Carnero et al. (2010) reported that the practice of dry needling in the active masseter MTrP reduces mechanosensitivity to pain in patients with TMDs . Blasco-We found that both dry needling and manual therapy are effective in increasing AMMO in patients with TMDs after the first session and after the interventions have finished, although no statistically significant differences between therapies were established. Previous investigations have reported that the MCID in active mouth opening varies between 6.5 and 9 mm . NeitherFinally, it is important to remark that patients with TMDs present clinical signs and symptoms of cervical disability or dysfunction . Pain inThe current study has several limitations. Firstly, the lack of blinding for participants and assessors may lead to an overestimation of the therapeutic effects of both interventions, reducing the accuracy of treatment effects, due to potential performance and detection biases. Secondly, the influence of the placebo effect and/or the natural evolution of TMD on our results cannot be determined. Thirdly, there was a lack of follow-up. Only one measurement was made at the end of both interventions , so the medium-, and long-term effects of these therapies have not been reported. In the future, it would be essential to carry out a similar study while seeking to reduce these limitations, so as to increase the generalizability and precision of the results.Findings present in this study are clinically relevant for clinical practice, due to showing that both therapies are effective in the management of patients with TMDs, allowing the physiotherapist to choose between invasive therapies, such as dry needling, or classical therapies, such as manual therapy, according to the preference of patients. In the future, it would be advisable to carry out more research, increasing the number of patients per group and the follow-up time after treatment.Dry needling and manual therapy are equally effective in the management of patients with TMDs, as the findings demonstrate comparable post-session and post-treatment results. At the end of treatment, both therapies showed significant reductions in pain and cervical disability, with medium effect size values; an improvement in active mouth opening, with effect size values close to medium; and an increase in Pressure–Pain Threshold in the active myofascial trigger points of masseters and lateral pterygoid muscles, with a small effect size value.


Objective: The study aim was to investigate the course of pain in rest and motion in seven different rheumatic diseases (RMD), prior and after multimodal spa therapy including low-dose radon treatment and at 3-, 6-; and 9-month follow up.Methods: Complete data from the radon indication registry including information on 561 subjects with RMD were analysed to explore the association of timepoint of measurement with pain in rest and motion. For this purpose, linear regression models adjusted for RMD-type, age, sex and body mass index (BMI) were applied.Results: The mean age of the sample was 55 years, the average body mass index was 26.8, and 275 subjects were women. Pain scores were significantly improved at all-time points compared to baseline. Pain courses were different for each RMD with the largest improvement seen in fibromyalgia.Conclusion: Timing spa facility visits according to RMD-specific pain courses may result in sustained pain reduction. Rheumatic musculoskeletal diseases (RMD) are among the most prevalent disorders worldwide. RMD is an umbrella term that refers to several conditions affecting the musculoskeletal system  among which osteoarthritis (OA), rheumatoid arthritis (RA), ankylosing spondylitis (AS), fibromyalgia (FBM), psoriatic arthritis (PsA) and low back pain (BP). Globally, approximately 1.71 billion individuals suffer from a RMD. These diseases are responsible for the largest proportion (17%) of global years lived with disability (YLDs) equalling approximately 149 million YLDs . While RDepending on the type of RMD, treatment options encompass non-pharmacological and/or pharmacological measures aiming at the reduction of pain and improvement of physical functioning as well as the stabilisation of symptoms. For some diseases, surgical measures are available –8. PharmAlternative or complimentary non-pharmacological treatment options have the potential to alleviate the burden by reducing the need for pharmaceutical uptake. In Europe, balneotherapy is among the most commonly prescribed non-pharmacological complementary therapies for different RMD 14). Balneotherapy is frequently described as part of health resort medicine (HRM) and may be considered a valid treatment option along with other HRM treatments like hydrokinesitherapy  and more generalized spa therapy which consists of a multimodal treatment approach  . Balneot.n = 38), the joints (n = 32), the spine and the joints (n = 22) or FBM (n = 8)  at baseline, 3.26  directly after intervention and 3.31  after 9 months. In patients with AS, predicted pain scores in rest returned towards baseline scores more rapidly  as well as insurance companies concerned with financial compensation and standardization of treatment regimens of patients with RMD. The current study adds to this evidence. Interestingly, patients with FBM showed the largest improvements in pain severity compared to baseline at 9 months’ follow-up while patients with AS showed the smallest improvement at this timepoint. This pleads for shorter treatment intervals for patients with AS than for patients with FBM. Simultaneously, it highlights the effectiveness of the multimodal spa-therapy treatment approach under study in FBM, a disease that is frequently considered challenging to treat due to its multifactorial nature .Strengths of the study comprise the relatively large study sample with complete data over a period of 9 months, the independence of data collection and solid statistical procedures for the generation of predictions. Importantly, the findings of the current study were able to support existing evidence from controlled environments in a real-life setting and give rise to further research exploring disease specific therapy responses of multimodal interventions.Several limitations arise from the use of data registries as was done in the current study. The collection of data was neither monitored nor performed by the researchers and potentially relevant confounders  for the explored association were not available. Moreover, data truncation at follow-up might have occurred resulting in over-or underestimation of the improvement in pain. For example, if patients who enrolled in the study did not complete follow-up questionnaires but had on average a larger improvement in pain than those considered in the current analyses, underestimation of improvement would be the result. On the same line, regression to the mean must be considered as potential reason for the observed change in pain scores. It must also be noted that data on the frequency of treatment before intervention were not systematically collected which might result in biased baseline values and ultimately underestimation of the improvement in first-time participants as those who received the intervention repeatedly likely have better baseline values. This might particularly be the case for patients with AS who are more frequently returning visitors to spa-facilities in the Gastein valley for secondary prevention of pain symptoms. In addition, pre-post observations based on patient reported outcomes are prone for response-shift bias, and results based on such observations should therefore always be considered carefully as improvement in health might be a reflection of individual perception of health rather than actual health , 35.Some of the subgroups of disease type  only included a limited number of patients, which led to wider confidence intervals and thus less accuracy in the estimates for these disease types. However, discussion with local physicians revealed that the number of patients with these disease types is notably smaller than in other groups of RMD revealing that the study is a reflection of the actual clinical situation in participating spas. As the register is still ongoing, future analyses with larger groups of these underrepresented disease types are possible and are being strived for by the authors.In conclusion, spa therapy including low-dose radon is associated with clinically relevant and significant improvement in patients with various types of RMD. The course of pain severity is different across the various types of RMD and should therefore be considered in the determination of treatment intervals and frequency. The findings of the current study may assist medical decision makers and insurance companies in the determination of such treatment intervals as timing of visits to spa facilities according to disease specific pain courses may result in sustained pain reduction and hence in enhanced quality of life and reduced use of health services.


Cases of an inguinal bladder hernia (IBH) are rare as the diagnosis may be challenging because patients are often asymptomatic or have nonspecific symptoms. When patients are symptomatic, normally they complain of urinary symptoms. Our patient initially presented to the hospital because he had a ground-level fall after having chest pain while transitioning from a bed to a wheelchair. Incidentally in the emergency department, he was found to have scrotal edema, which was later diagnosed as inguinal bladder herniation. The patient did not have any further episodes of chest pain or abdominal pain once he was given medicinal therapy for his IBH. Surgery is usually the definitive treatment for inguinal bladder herniation, but our patient wished to try medicinal therapy and follow-up outpatient.  Inguinal bladder hernias (IBHs) are a rare disorder, and it has been reported that IBHs account for 0.4-3% of adult inguinal hernia cases in western countries . AlthougAn 84-year-old male with a past medical history of right nephrectomy secondary to renal mass and chronic kidney disease stage IV arrived at the emergency department after a ground-level fall at home while transitioning from a living room chair to a wheelchair. The family was unable to lift him off the ground, so they called emergency medical services (EMS) for assistance. When EMS arrived, he had been on the floor for approximately 70 minutes, and they recommended taking the patient to the emergency department for evaluation due to the patient complaining of intermittent chest pain. The patient reported that over the past two months, he had noticed that his scrotum had increased in size. While his scrotum was increasing in size, he noticed that he was developing suprapubic abdominal pain that was radiating to his inferior sternum. He was unable to fully describe his chest and abdominal pain but endorsed that it was worse when he was trying to strain to urinate. Initial vital signs were blood pressure of 103/47 mm/hg, pulse 95 beats per minute, temperature 98 °Fahrenheit, respiratory rate 28 breaths/min, and oxygen saturation on room air 99%. Initial labs are available in Table During the physical examination that was performed in the emergency department, he was seen to have a large non-tender scrotum. An ultrasound was ordered to better assess his scrotum. The ultrasound showed that he had a very large fluid collection in the scrotal sac, and they recommended computed tomography (CT) scan to better evaluate. CT scan Figures , 3 showeInguinal hernias are thought to have both a congenital and an acquired component, and some data point to the possibility that genetics may also be involved . PatientA small inguinal bladder herniation usually presents with no symptoms, but a large IBH tends to produce symptoms including swelling in the groin and/or symptoms of lower urinary tract infection . PatientIBHs are typically treated surgically with a herniorrhaphy . When thWe would expect abdominal pain in certain patients with a large IBH, but chest pain has not been documented with IBHs. During our literature review, we were not able to find any cases that showed patients with a large IBH causing associated chest pain. Here, we presented an interesting case of a patient who had been complaining of intermittent chest and abdominal pain that was caused by his large IBH. He was diagnosed with an IBH and chose to not pursue surgical intervention but only a medicinal approach. With medicinal therapy, his scrotal swelling improved, and eventually his chest pain completely resolved. Normally patients with IBHs experience urinary symptoms, but from a literature review, chest pain has never been associated. This case also brings an important focus on physical examination, as our patient did not initially present with the complaint of scrotal edema. Without a thorough physical examination revealing scrotal edema, his initial differential with abdominal and chest pain would have been vast.


Lumbar spinal stenosis (LSS) patients have been reported to have neuropathic pain and central sensitivity syndrome (CSS). These associations have been reported in other diseases but are unknown in preoperative LSS patients. We aimed to investigate the association between neuropathic pain and CSS in preoperative LSS patients using the painDETECT and the Central Sensitization Inventory (CSI) questionnaires.  This cross-sectional study was conducted from November 2021 to March 2022. The data were collected regarding demographics and pain, including neuropathic pain, numbness, LSS severity, physical function, quality of life, and CSS. Patients were divided into two groups, patients with acute and chronic pain, and further classified into three categories based on the clinical phenotype of patients in each group. Independent variables included age, gender, type of LSS , Numerical Rating Scale of leg pain, CSI, and the Zurich Claudication Questionnaire (ZCQ) for symptom severity and physical function. The dependent variable was painDETECT. Multiple regression analysis using the forced entry method examined the association between painDETECT and CSI. β = 0.468, p < 0.001) and ZCQ for symptom severity  were significantly associated with the painDETECT, explaining 47.8% of the variance in the painDETECT score.  Of the 119 patients with preoperative LSS, 106 were included. The mean age of the participants was 69.9 years, and 45.3% were female. Neuropathic pain was present in 19.8%, and CSS was present in 10.4%. The CSI ( There is an association between neuropathic pain and CSS in patients with preoperative LSS using the painDETECT and CSI questionnaires. Lumbar spinal stenosis (LSS) is a degenerative disease impacting daily living and quality of life, with neuropathic pain being the primary complaint , 2. A prIn this study, we aimed to examine preoperative LSS patients for potential associations between neuropathic pain and CSS, hypothesizing that neuropathic pain and CSS would not be related. Rejecting this null hypothesis would imply a latent relationship between neuropathic pain and CSS, providing valuable insights for managing and treating pain in LSS patients.This cross-sectional study was conducted between November 2021 and March 2022 at Shinagawa Shishokai Hospital. The study was approved by the Shinagawa Shishokai Hospital Research Ethics Committee (reference no. 202101) and conducted in compliance with the Declaration of Helsinki. All participants provided written informed consent to participate following a comprehensive discussion about study procedures and objectives. The study methods were compliant with the STROBE checklist .We included patients (1) who were hospitalized for surgery after being diagnosed with LSS, (2) who agreed to participate in the study, and (3) who were able to read the Japanese language well enough to complete the questionnaires independently. We excluded the following patients: (1) those with histories of musculoskeletal disorders and (2) those who did not complete the questionnaires.We collected data on age, gender, height, weight, body mass index (BMI), duration of LSS symptoms, and details of conservative treatments before surgery from medical records. Patients reported the duration of LSS symptoms in months or years. If the period was in years, it was converted to months. Chronic pain is pain that lasts or recurs for over three months . This stA taxonomy based on clinical phenotype was used to assess LSS symptoms. Based on the clinical phenotype of the patients, we classified them into three categories: Type A, neurogenic claudication pain; Type B, neurogenic claudication sensory/balance; and Type C, radicular unilateral leg pain, based on the report of Comer et al. .The Schizas classification was used to assess the radiological severity of LSS . The parThe Numerical Rating Scale (NRS) was used to rate the average low back, leg, and numbness intensity on the assessment day. A score of 0 indicated no pain, and 10 indicated the worst pain imaginable.The painDETECT was used to screen for neuropathic pain . This quThe Central Sensitization Inventory (CSI) was used to evaluate CSS. The CSI is a self-report questionnaire that does not determine causality but can assess CS-related symptoms. The CSI comprises 25 items with scores ranging from 0–4 . The higThe Zurich Claudication Questionnaire (ZCQ) was used to evaluate the LSS comprehensively . The 12-The EQ-5D-5L was used to assess quality of life (QoL) . The JapThe primary outcome was painDETECT and CSI. Multiple regression analysis was performed to evaluate these associations with painDETECT as the dependent variable and CSI and other items as independent variables. Details are described in the Statistical Variables section.Several strategies were implemented to minimize bias. All PROMs utilized standardized questionnaires with established reliability and validity in Japanese. Patients who required assistance comprehending the questionnaires or had incomplete data were excluded to guarantee a comprehensive data analysis. Moreover, the assessment date was designated as the day before surgery. Patients were informed that the evaluator and therapist might not be the same individual, ensuring that their questionnaire responses would not adversely affect their treatment.G∗Power (version 3.9.6.1) [∗Power uses the a priori power analysis method to calculate the necessary sample size based on the selected statistical analysis, desired power, and other input parameters. We entered the effect size, α error, power, and the number of predictors into the F tests to calculate the sample size. The statistical test used was a linear multiple regression with a fixed model, focusing on R2 deviation from zero. The power analysis type involved calculating the required sample size based on α, power, and effect size.” Specifically, we set the effect size f2 to 0.15, αerr prob to 0.05, power to 0.8, and the number of predictors to 7, as Cohen [The sample size was calculated using 3.9.6.1) , 30. G∗Pas Cohen  recommenParticipants' characteristics were summarized with descriptive statistics. Quantitative variables were presented for mean, standard deviation, minimum, maximum, median, interquartile range, and 95% confidence interval. Counts and percentages summarized categorical variables.t-tests were used for variables meeting the normality assumption (p > 0.05). Otherwise, the Mann–Whitney U test was used. Categorical variables were examined with a chi-square test (expected frequency >5) or Fisher's exact probability test. Independent t-tests were used for the following items: height, painDETECT, ZCQ, ZCQ for symptom severity, and ZCQ for physical function. Independent Mann–Whitney U tests were used for the following items: age, weight, BMI, duration of LSS symptoms, number of spinal stenosis, NRS for LBP, leg pain, numbness, CSI, and EQ-5D-5L. Independent chi-square tests were used for the following items: gender. Independent Fisher's exact test was used for the following items: classification of LSS by the site of symptom appearance, grade of spinal stenosis according to Schizas, and conservative treatment. Two groups, acute and chronic pain, were classified into three types, each using a clinical phenotype. Each factor's correlation was evaluated using Spearman's rank correlation coefficient (r). In addition, multiple regression analysis using the forced entry method was performed using painDETECT as the dependent variable and age, gender, and grade of classification of LSS by the site of symptom appearance, CSI, ZCQ for symptom severity, and ZCQ for physical function as independent variables to determine which factors affected the painDETECT score. Regarding multicollinearity, we confirmed that the analysis of variance (VIF) for all independent variables was <5. All statistical analyses were performed using EZR  and GUI of R .For all variables, the Shapiro–Wilk test was used to assess the normality of the data distribution. For comparing continuous variables in the two acute and chronic pain groups, independent n = 9), inability to understand (n = 1), difficulty understanding Japanese (n = 1), and incomplete data (n = 2). Finally, 106 participants satisfied all criteria and agreed to participate. Characteristics of the participants and clinical features of the total sample are shown in We screened 119 participants with LSS; 13 (8%) were excluded due to previous surgery , CSI , ZCQ for symptom severity , and ZCQ for physical function  and negatively associated with the EQ-5D-5L . The CSI was positively associated with the NRS for low back pain, leg pain, and numbness , ZCQ for symptom severity , and ZCQ for physical function  and negatively associated with the EQ-5D-5L .β = 0.468, p < 0.001) and ZCQ for symptom severity  were significantly associated with the painDETECT, explaining 47.8% of the variance (r2 adjusted: 0.478, The multiple regression analysis was performed using a forced entry method. The CSI (This was the first study to investigate the potential association between neuropathic pain and CSS in preoperative patients with LSS using painDETECT and CSI. The results showed a significant association between the painDETECT and CSI by multiple regression analysis. Furthermore, we also found an excellent convergent association between painDETECT and CSI, as 47.8% of the variance was explained. These findings confirm the association between neuropathic pain and CSS in preoperative patients with LSS. The painDETECT and CSI were nonsignificant between the two groups for acute and chronic pain. No significant association was found between painDETECT and CSI in classifying LSS according to clinical phenotype.Similar to previous studies, leg symptoms in LSS included a neuropathic pain component in this study . As leg Furthermore, in a previous study in which patients with LSS were classified by painDETECT, 17.6% had neuropathic pain , and 17.However, an essential reason for the significant association between the painDETECT and the CSI might be the overlap between each other's questions. The questions “Does your pain radiate to other regions of your body?” in painDETECT and “I feel pain all over my body” in CSI are considered overlapping. In addition, painDETECT provides seven questions on pain symptoms. CSI has provided a question on “My muscles feel stiff and achy,” “My legs feel uncomfortable and restless when I am trying to go to sleep at night,” and “I have pain in my pelvic area.” Patients may have responded to these question scales as identical. Therefore, caution is needed in interpreting the relevance of these questionnaires. The exact mechanism by which compression of the lumbar spinal canal and neural foramen manifests as symptoms is not yet understood . TherefoOne of the limitations of this study is that the subjects were only patients with preoperative LSS, which does not allow for application to primary care or postoperative patients. Because we only examined preoperative patients with LSS from a single institution, our results may need to be more generalizable to other patient groups or settings. Furthermore, LSS has been reported to present with various symptoms, including NIC and LP, with different symptom mechanisms. However, the present study was not conducted on a symptom-by-symptom basis. Future surveys by symptom type would yield new results. Second, neuropathic pain and CSS were assessed using painDETECT and CSI. Diagnosing neuropathic pain requires detailed assessment, including neurologic examination . CSS is First-line treatment for neuropathic pain is pharmacologic therapy. When ineffectiveness is not expected, invasive approaches are considered . A multiThis study investigated the potential association between neuropathic pain and CSS in patients with preoperative LSS using painDETECT and CSI. These results suggest neuropathic pain was associated with CSS in patients with LSS preoperatively assessed by painDETECT and CSI.


Vertebral osteomyelitis (VO) is a severe clinical entity associated with significant morbidity and mortality. Several studies have showed that successful treatment of VO patients leads to significantly improved quality of life (QoL). Nevertheless, QoL levels of these patients remained below those of the general population. There are rarely studies focusing on predicting factors for favourable QoL after surgically treated VO. The aim of this study was to identify factors influencing positively the QoL of patients undergoing surgery for VO.We conducted a prospective monocentric study including surgically treated VO patients from 2008 to 2016. Data were collected before (T0) and 1 year (T1) after surgery. Primary outcome was favourable QoL defined as back pain with disability restricting normal life activity with a cutoff value ≥ 12 on Oswestry Disability Index (ODI).Ethical approval was given by the Faculty of Medicine at the University of Cologne (09-182).p = 0.022), lower albumin  an ASA score ≤ 2 , and a lower preoperative leg pain on the VAS  were identified as independent risk factors for favourable QoL. Interestingly, the absence of neurological deficits was not predictive for a favourable outcome by means of QoL.A total of 119 patients surviving 1 year after surgically treated VO were analysed. Favourable QoL was achieved in 35/119 patients. On multivariate analysis, younger age  in our cohort achieved favourable QoL by means of ODI. Our findings can facilitate an estimation of the prognosis when informing the patient before surgery, and underscore that spine disability questionnaires, such as ODI, measuring QoL, are mandatory to evaluate comprehensively the outcome of this entity. Vertebral osteomyelitis (VO) is a severe clinical entity associated with significant morbidity and mortality . SeveralThere are only few studies focusing on a favourable outcome or on predicting factors for a successful surgical treatment of VO, in particular addressing means of QoL. Available data are mainly based on retrospective analyses and inhomogenous populations where the assessment of risk factors for sequels after surgery remains unclear.In this context, the goal of this study was to assess factors influencing favourable QoL of surgically treated VO patients by means of ODI, which were recorded in a prospective study.From 2008 until 2016, patients with diagnosed VO at the Department for Orthopaedics and Trauma at a tertiary referral hospital were enrolled into the European “Spine Tango” register. Study inclusion criteria were the presence of characteristic back and/or leg pain plus characteristic magnetic resonance imaging (MRI) or an abscess or vertebral body destruction detected by computed tomography (CT). All cases were discussed interdisciplinarily between an infectious diseases specialist and an orthopaedic surgeon to confirm the diagnosis of VO. Cases that were not clearly diagnosed as VO by our strict criteria, but showed other underlying diseases (e.g. tumour or osteoporotic fractures) were excluded from the study. Adult patients (≥ 18 years of age) with indications for surgery were considered for analysis.The following data were prospectively collected after enrolment in the European “Spine Tango” register: age, sex, length of hospital stay, affected spine segment and American Society of Anesthesiologists (ASA) score. The ASA Physical Status Classification System was developed in 1941 to classify patient comorbidity and is widely used by clinicians. ASA Class I is defined as a normal healthy patient, and Class V as a moribund patient not expected to survive without surgery. To assess QoL, the ODI was used. The ODI is a self- administered questionnaire and consists of tenitems. The first section rates the intensity of pain, whereas the rest describes its disabling effect on typical daily activities. The sum of the ten scores results in a score from 0 to 100. A lower average score demonstrates a higher QoL. The ODI score was collected preoperatively (T0) as well as after 1 year (T1). To measure the intensity of the pre-operative pain, visual analogue scale (VAS) from the Core Outcomes Measures Index (COMI) was used. The COMI consists of six items including two visual analogue scales (VAS), measuring back and leg pain that result in a score from 0 to 10.In addition, the following variables were recorded for all VO patients undergoing surgery: bacteraemia, causative pathogens, body mass index (BMI), relevant comorbidities  and conditions , laboratory, radiological data, presence of psoas abscess or empyema and pre-operative neurological deficits based on the Frankel scale. The Frankel scale classifies the extent of the neurological/functional deficit into five grades. Grade A shows no motor or sensory function below the level of lesion, whereas Grade E is defined as a normal motor and/or sensory function.Primary end point was favourable QoL defined as an ODI score < 12 points 1 year (T1) after surgery according to the reported cutoff values for back pain without disabilities allowing a normal everyday life .VO patients with bony destruction of the endplates, suspected instability and intraspinal empyema were treated surgically. In patients with progressive neurological failures with or without impending sepsis or haemodynamic instability, surgical intervention was performed immediately. Further indications were pain caused by spinal instability, progressive deformity, and/or intraspinal empyema, or failure to respond to conservative antimicrobial therapy. The surgical procedure was chosen according to vertebral destruction. If only an abscess or even an empyema was present, intraspinal debridement was performed. In cases of bony destruction and/or instability, additional intercorporal fusion was carried out. If a reconstruction of the ventral column was indicated but not possible from the dorsal approach due to the extent of the bony destruction, a two-staged treatment was chosen: debridement and instrumentation in the first surgery and corporectomy/spondylodesis with implantation of iliac crest grafts, intervertebral cages or vertebral body replacement in the second surgery . In the lumbar spine, fusion was performed in one stage in a posterior lumbar interbody fusion (PLIF) or in two stages in an anterior lumbar interbody fusion (ALIF) technique.Staphylococcus aureus bacteraemia; disseminated infectious complications). Therapy for specific microorganisms was applied according to the guidelines  [Whenever possible, antimicrobial therapy of VO was directed against the identified specimen. In culture-negative cases empirical therapy was administered with our local standard regimen  as MRSA rates are low in Germany. In general, postoperative antibiotic treatment was administered intravenously for 14 days, followed by a highly bioavailable oral antimicrobial therapy oralization with a duration of 6–12 weeks in total depending on the severity of disease deferred response or risk factors . A longer intravenously therapy was applied when indicated  –7.χ2 or Fisher`s exact test, as appropriate. Ordinal data are compared by median test for independent samples. To identify independent factors for a favourable outcome (ODI < 12 points), all variables found to be clinically relevant or univariately significant were included in a multivariable logistic regression model. Variable selection (forward and backward) was then applied and the best model according to the Akaike information criterion (AIC) was selected. All statistical tests were two- tailed and p ≤ 0.05 was considered to indicate statistical significance. Statistical analyses were performed in an explorative descriptive sense.All statistical analyses were performed using IBM SPSS Statistics Version 26. Categorial variables were compared using From 2008 until 2016, 233 inpatients with confirmed VO were surgically treated in our department. A pre-operative ODI assessment (T0) was possible in 172 patients. After 1 year,119 patients were available for evaluation at T1 . In five patients (4%), a pure decompression was sufficient. In 51 patients (43%), a one-stage procedure was possible including 26 cases (22%) of PLIF. In 68 patients (57%), a two-stage procedure for ventral stabilization was necessary including 43 (36%) ALIFs. In 61 cases (51%), corporectomy was performed. The baseline characteristics of patients with favourable and unfavourable QoL are shown in Table Mean ODI values improved significantly from 75.4 SD ± 18.5) at T0 to 29.1 (SD ± 22.1) at T1 (8.5 at T0p = 0.007), a lower preoperative COMI score  and lower preoperative leg pain on the VAS scale .One year after surgery (T1), 35 (29%) patients had favourable QoL (ODI < 12 points) and 84 (71%) patients had unfavourable QoL (ODI ≥ 12 points). Patients with favourable QoL more frequently had an ASA score ≤ 2 at baseline , lower albumin  an ASA score ≤ 2 , and a lower preoperative leg pain on the VAS  were significantly predictive for favourable QoL after surgery , it is clear that the difference of one point is not clinically significant and therefore does not require further attention.Interestingly, a lower preoperative leg pain measured by VAS was also associated with favourable QoL. Recent studies have already proved that back pain plays an important role as the key symptom of VO. Our results pointed out that leg pain is not only important, but also an independent predictive factor for favourable QoL. In 2019, Kim et al. already showed the importance of radiating pain distinguishing postoperative VO (PVO) from native VO (NVO) significantly, with NVO as the more severe disease with a higher mortality .The strengths of the current study are the prospective study design with uniform 1-year follow-up that yields more detailed and robust information with strict inclusion criteria compared to case series or retrospective cohort studies. By focusing on the threshold of the ODI to define favourable QoL, our findings add important new clinical relevant information.This study's limitations include possible selection bias, since it is a single-centre study from a tertiary care hospital primarily treating multimorbid patients and/or patients with complicated case histories. By excluding patients having died within 1 year after surgery, other predictive factors might be missed. We had to transfer threshold values of ODI from acute and chronic back pain to VO, as specific values are missing; nevertheless, a transfer is reasonable as it is known that even after successful treatment the QoL of VO patients is comparable to that of those suffering from chronic back pain. In the future, specific thresholds for QoL scores in VO patients need to be defined.One-third of surgically treated VO patients (29%) in our cohort achieved favourable QoL by means of ODI. In addition to the known factors, age and ASA score, we were able to demonstrate that even preoperative leg pain was able to predict favourable outcome, so that greater attention should be paid to this parameter. On the other hand, preoperative neurologic deficit was not predictive of QoL after surgical treatment of VO. Our findings can already facilitate an estimation of the prognosis when informing the patient before surgery, and underscore that spine disability questionnaires, such as ODI, measuring QoL are mandatory to evaluate comprehensively the outcome of this entity.