Though chronic pain is widespread, affecting about one-fifth of the world’s population, its impacts are disproportionately felt across the population according to socioeconomic determinants such as education and income. These factors also influence patients’ access to treatment, including pharmacological pain management.A scoping review was undertaken to better understand the association of socioeconomic factors with physicians’ pain management prescribing patterns for adults living with chronic pain.An electronic literature search was conducted using the EMBASE, CINAHL, SCOPUS, and Ovid MEDLINE databases and 31 retrieved articles deemed relevant for analyses were critically appraised.The available evidence indicates that patients’ lower socioeconomic status is associated with a greater likelihood of being prescribed opioids to manage their chronic pain and a decreased likelihood of receiving prescription medications to manage migraines, rheumatoid arthritis, and osteoarthritis.These results suggest that individuals with lower socioeconomic status do not receive equal prescription medicine opportunities to manage their chronic pain conditions. This is influenced by a variety of intersecting variables, including access to care, the potential unaffordability of certain therapies, patients’ health literacy, and prescribing biases. Future research is needed to identify interventions to improve equity of access to therapies for patients with chronic pain living in lower socioeconomic situations as well as to explain the mechanism through which socioeconomic status affects chronic pain treatment choices by health care providers.SES: socioeconomic status; RA: rheumatoid arthritis; IV: intravenous; SC: subcutaneous; bDMARDs: biological disease-modifying antirheumatic drugs; DMARDS; disease-modifying antirheumatic drugs; TNFi: tumour necrosis factor inhibitors; NSAIDs: non-steroidal anti-inflammatory drugs International Classification of Diseases,1,2 chronic pain is “an unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage … that persists or recurs for longer than 3 months.”3 Chronic pain affects approximately one-fifth of the population and is a leading cause of disability and disease burden.5 Given that chronic pain is a complex and multidimensional experience whose assessment, study, and management are influenced by a variety of biopsychosocial contexts,6 it is not surprising that a variety of studies have found that patients’ socioeconomic status (SES) can affect their experiences, treatments, and health outcomes.7–9 Patients’ chronic pain experiences have been shown to be affected by factors such as their gender, ethnicity, social class, income, education, and the neighborhood in which they reside.9–11 The Canadian Pain Task Force12 agrees that such factors play a role in explaining the inconsistent and inequitable experience of pain and access to pain care in Canada. Therefore, among the six recommendations that the Canadian Pain Task Force has suggested to the Canadian federal government to improve the prevention and management of chronic pain are those specifically related to improving both equitable access to pain care and ensuring “equitable approaches for populations disproportionately impacted by pain.”Recognized to be a disorder unto itself in the 11th revision of the 13–17 In addition to being a risk factor for the development for disabling chronic pain,19 lower SES has been associated with a higher incidence of other medical comorbidities that can amplify chronic pain.18A better understanding of the role of societal inequities in the development and severity of chronic pain is necessary in order to actualize such recommendations. Lower SES has been correlated with increased chronic pain incidence, severity, and pain-associated and psychosocial disability in a variety of studies performed using methodologies ranging from random population sampling to health questionnaires and surveys to prospective cohort studies following patients from birth to adulthood.20–22 Studies report that living or growing up in a lower income household is associated with an increased risk of developing or reporting chronic pain and an increased prevalence and severity of chronic pain.23–28 As wealth increases, the degree to which chronic pain interferes with the performance of activities of daily living decreases.29 Self-perceived economic hardship has also been shown to exacerbate chronic pain.22 Income can affect health outcomes in terms of access to resources within health care, as well as resources outside of health care related to healthy living, such as access to healthy food and opportunities for physical activity.20 Lower-paying jobs may be associated with greater occupational hazards or be more physically demanding and so predispose to the development of chronic pain.30 For patients with lower income and chronic pain, this has meant decreased access to pain therapies or resources to modify their living or work environments to decrease their pain and/or improve their function.20Associations and interactions between lower SES and chronic pain are due in part to income-related factors. Income has been considered in different ways in chronic pain–related studies, including as measured household income, household wealth that incorporates the financial resources accumulated over a lifetime, employment type, indexes that include a combination of housing tenure, car ownership, and employment status, as well as self-reported ratings of economic hardship and daily financial worry.31 In health research, education is often measured by asking participants to identify the highest level of education that they have completed.32 Lower educational achievement has been associated with a higher prevalence of pain, more severe pain, and greater occupational and overall disability.32–34 Higher educational achievement was found to be a protective factor for developing chronic pain when controlling for occupational class and working conditions.32 A variety of hypotheses have been proposed to explain these relationships between lower levels of education and chronic pain. Higher levels of education can facilitate patients’ improved communication with physicians.34 Patients are therefore better able to access and understand treatment information, express themselves and their concerns, appropriately use care resources, and navigate health care systems more effectively.34–37 Physicians are more likely to spend more time with patients with higher SES, provide them with information, and justify treatment suggestions compared to patients with lower SES.38–40 Other studies suggest that lower levels of education are associated with fewer vocational options and occupations that require more physical work and thus workers are more prone to injuries and have less autonomy.41–46 Additionally, lower levels of education have been suggested to be a proxy for maladaptive pain beliefs and ineffective and passive coping strategies that exacerbate chronic pain.47–50 Roth and colleagues6 found that the belief that chronic pain is synonymous with “harm” and catastrophizing accounted for the association between lower educational achievement and severe disability secondary to chronic pain. They speculated that lower levels of education preclude patients’ abilities to develop accurate models of health and illness such that they develop ineffective ways to manage their pain, such as catastrophizing, praying, and hoping.47Closely linked to considerations of income and SES are those related to patients’ educational achievements. Education is associated with the acquisition of beliefs and knowledge that enables individuals to integrate health behaviors into their lifestyles and provides a sense of control over one’s own health.51 Therefore, understanding the factors that influence prescribing patterns is important for assessing the quality of care provided to patients. However, though previous studies have evaluated the influence of guidelines on the pharmacological management of chronic pain, the association of patients’ SES on such patterns is not well understood.52–55 The aim of this study was to better identify this knowledge gap by surveying the available literature, examining how research on this topic has been conducted, and providing an overview of its focus and the available evidence. The aim was not to produce a “critically appraised and synthesized result to answer a particular question,” which would be in keeping with a systematic review. Thus, a scoping review was deemed to be the most appropriate method of accomplishing these aims.56 Examination of this topic has been suggested to be important given the impetus for chronic pain to be considered a pressing public health problem and increased recognition of and calls to address the issues that contribute to the inequitable burden of chronic pain in society.57 The demonstration of how the COVID-19 pandemic has disproportionately affected patients with chronic pain living with low SES makes this review topical because it seeks to contribute to greater understanding of how access to chronic pain care can be improved for these patients.58 The information obtained from this review is relevant for clinicians, hospital administrators, and politicians with respect to becoming better informed of the barriers to accessing care for chronic pain. The results of this review may also be beneficial for establishing guidelines to deliver equitable pain management services to patients from differing socioeconomic backgrounds.There is evidence available to suggest that these aforementioned components of patients’ SES can have an association with physician medication prescription patterns. The writing of prescriptions is the most frequent medical intervention performed by physicians and is an integral component of the health care system.4 We focused on studies that included chronic pain unrelated to cancer and studies that addressed common chronic pain conditions. We included studies related to arthritis, back/neck pain, headache disorders, fibromyalgia, and myofascial pain syndrome.A scoping review was completed to assess the association of SES on physician prescribing patterns for adult patients experiencing chronic pain. The search strategy extracted articles that assessed the association of SES on physician prescribing practices for chronic pain management in adults. This review focused on studies addressing income and education given the importance of these determinants as previously described. Chronic pain was considered as “pain which has persisted beyond normal tissue healing time,” which, in the absence of other factors, is generally taken to be 3 months.An electronic search strategy was established in collaboration with an information specialist librarian. The searches completed for this review were restricted to those in the English language and published between the years 2000 and 2021. The electronic databases used for the searches included EMBASE, CINAHL, SCOPUS, and Ovid MEDLINE. The key words related to SES used in the search included “social class,” “social status,” “education,” and “income.” The search terms related to prescribing practices included “physician prescribing practices,” “practice patterns,” and “inappropriate prescribing.” The search terms related to chronic pain that were used for this literature search were as follows: “chronic pain,” “persistent pain,” “arthritis,” “back pain,” “neck pain,” “headache disorders,” “fibromyalgia,” and “myofascial pain syndromes.” The search strategy was conducted to a final date of February 1, 2021, and was continually updated throughout the completion of this review. The search strategy identified 3492 articles to be included in the title and abstract screening for the scoping review. Any duplicate records were removed prior to screening.www.covidence.org) to assist with the overall management of the articles for the review. The articles identified by either one or both reviewers as possibly relevant were retrieved for a full-text review. The second level of screening involved a full-text review based on the eligibility criteria previously outlined. A full paper analysis was completed to ensure that the study provided sufficient information relevant to the objectives of this scoping review. Following the second level of screening, the reference lists of the relevant articles were also manually searched to identify additional references. Disagreements arising between the two independent reviewers during the screening process were resolved by consensus. Thematic analysis of the selected studies was performed independently by each author and then reviewed together to develop consensus. This was an iterative process.The overarching goal of the scoping review selection was to identify and review any available evidence within the eligibility boundaries previously outlined. Specific screening questions were developed for all levels of the assessment and two independent reviewers performed the screening process. Two levels of screening were completed to identify the relevant studies for this scoping review. The first level of screening included a title and abstract review for the articles retrieved from the electronic search in order to remove any studies that did not relate to the review topic. The reports obtained from this screening process were uploaded to Covidence  did not cover pain management,90–112 (2) did not deal with pharmacological therapies,113–141 (3) were not related to prescribing,142–247 (4) were not related to the pain conditions outlined in the inclusion criteria,248–266 (5) did not consider either income or education,267–313 (6) were epidemiological,314–333 (7) were reviews,334–350 (8) were abstracts that were subsequently published as full-length manuscripts that appeared in the search,351–355 (9) did not provide enough information to determine whether there were differences between SES groups,357 (10) were repeated,11 or (11) were not in English.358 A PRISMA  flow diagram summarizes the article management process used for this review . These latter findings are consistent with those described by Shmagel and colleagues,76 who found that 94% of patients with chronic back pain to whom opioid prescriptions were provided had less than a college education.Looking at SES from an education perspective, patients with lower levels of education were found to have higher rates of opioid use.68 identified that individuals with a lower SES were more likely to utilize opioids to manage their chronic pain for a longer time, which resulted in an increased risk of opioid overdose–related emergency room visits and hospitalizations. In addition, Chuang and colleagues63 found that patients who used opioid analgesics to manage their chronic pain were more likely to be unable to work due to disability and were more likely to receive social security income. When controlling for potential confounders in multivariable analyses, patients who used opioid analgesics had three times the odds of being unable to work due to disability compared with nonusers.63The use of opioid prescriptions for those living with chronic pain in lower SES situations was found to further disadvantage them. Kuo and colleagues71 did not find that opioid prescriptions were more likely to be prescribed to African American patients of low SES. Additionally, Tamayo-Sarver and colleagues79 identified that “desirable” patient characteristics increased the likelihood of receiving a prescription of opioids for chronic pain, by which they meant patients with higher SES, who were employed, and who had an established relationship with a primary care physician.(p1239) Other studies found that lower education was found to be a weaker predictor of opioid use than income status67 or not predictive at all.65A limited number of the studies included in this review did not identify an association between SES and the likelihood of receiving an opioid prescription for chronic pain. For example, Nampiaparampil and colleagues89 Patients with low personal incomes were more likely to be prescribed glucocorticoid monotherapy rather than a DMARD.89 Living in communities associated with lower SES was also found to be negatively associated with receipt of a DMARD prescription,87 and analyses demonstrated that this effect was evident even beyond the effect of individuals’ low personal income.87 Such a relationship was seen at even larger scales at the county and even national levels, even with the existence of prescribing guidelines.73 The time until initiation of a biological DMARD was also significantly longer for patients living in lower SES areas.80Several studies included in this scoping review identified a link between SES and the likelihood of receiving prescriptions of a disease-modifying antirheumatic drug (DMARD) for rheumatoid arthritis. Patients with greater financial resources were found to have a higher probability of being prescribed a biological DMARD.81 gauged patients’ household income from income tax files and found that despite the presence of a universal national health care insurance system in Taiwan, patients were less likely to receive newly enlisted nonsteroidal anti-inflammatory drugs if they had lower incomes. The use of tumor necrosis factor inhibitors was also less likely for patients with lower SES.66Lower income was also associated with lower odds of being treated with newer or other medications for arthritis. Wang and colleagues69 Patients were more likely to use triptans if they had insurance coverage88 or higher incomes, which meant annual household incomes exceeding $60,000 compared to less than $22,500,62 exceeding $40,000 compared to less than $22,500,84 or high income levels compared to middle, lower, or poor income levels when income was referenced with respect to a federal poverty line threshold.88 Achievement of at least college-level education was also seen to be associated with an increased likelihood of using a triptan medication.88 It was only an American national stratified sample survey of households using a mailed questionnaire that found that income levels were associated with insignificant differences in rates of prescription medication use for migraine headaches.83Studies analyzing the variability in triptan prescriptions for patients with migraines living in different socioeconomic situations mostly showed that lower SES was associated with a decreased propensity to receive them.361 Indeed, as Karran and colleagues339 wrote, “Health outcomes are explained less by the quality and availability of medical care than they are by the context and circumstances of people’s lives.(p2476) Further, Brady and colleagues7 noted that “as pain represents higher-order processing, a product of individual interpretation and meaning, it is important that research into pain seeks to understand the ethnocultural and socioenvironmental contexts that shape the way people live with and manage pain.”(p435)This scoping review looked at the association of SES on physician prescribing patterns for adult patients living with chronic pain. Chronic pain is recognized to be affected by a variety of biological, psychological, and social factors and therefore patients’ socioeconomic circumstances affect their pain and pain management experiences.363 An approach was utilized to maximize the identification of all relevant studies associated with arthritis, back/neck pain, headache disorders, fibromyalgia, and myofascial pain syndrome, income and education, and prescribing patterns. Most of the studies included in this review utilized data collected from a variety of clinical settings. Many of the included studies had large cohorts of patients across different geographic locations, such as the United States,82–89 Canada,86 Australia,72 Norway,75 Romania,64 Sweden,66 Taiwan,81 and a multinational trial.73 This increases the generalizability of the findings but also means that the results need to be interpreted in the context of the heterogeneity of the health care systems in which the patients were studied. For example, some studies were performed in countries with universal health care coverage, whereas others were performed in systems in which patients bear more financial responsibility for their health care and prescription medications. Even countries with national universal health care systems may not have universal prescription medication coverage, as is the case in Canada, which means that patients with lower income may face challenges affording medications for pain management.A scoping review was selected because the aim was to synthesize the evidence available regarding the associations of SES with specific chronic pain conditions and identify any knowledge gaps. It is recognized that SES comprises more than just one construct and so factors such as income and education were considered because these are thought to be valid and stable constructs.71 This was due to the costs associated with other types of treatment as well as challenges with taking time to access other services.364 Nielsen and colleagues72 found that having private insurance facilitated access to nonopioid therapies as well as access to specialists. They additionally found that the use of higher doses of opioids was associated with greater challenges in getting to pharmacies and physicians, including specialists. As has been pointed out, the lack of coverage for a variety of nonopioid pain therapies therefore means that patients with lower SES may be unable to access more “widely recommended treatment options.”365 Prescribers’ recognition of this may thus lead them to overrely on opioids for pain management for patients with lower SES. At the same time, Grol-Prokopczyk67 suggested that caution is required as efforts are made to address the opioid crisis and the “crisis of undertreated pain” by limiting access to opioids: “To shut the door to one form of pain treatment without ensuring that others are open will likely exacerbate the latter crisis, and perhaps the former too, if those unable to access prescribed drugs switch to illicit ones.”(p1017)A variety of hypotheses have been suggested to explain the observed relationships between SES and opioid prescribing and use rates. It was thought that lower SES was associated with decreased resources and therefore abilities to access nonopioid therapies.76 There is evidence to support this assertion because taking into account health literacy when educating patients about opioid use for pain was an effective way of changing patients’ perceptions about their pain.366–368 The contrary finding by a few studies that higher SES was associated with greater rates of opioid prescribing was suggested to be potentially explained by physicians’ concerns that patients with lower SES would be less likely to follow their prescribing and treatment recommendations and more likely to misuse opioids.370From an education perspective, it has been suggested that patients with lower levels of education may have been found to be more likely to use or be prescribed opioids because they were not as well-informed about their lower efficacy in pain management and their associated side effects.89 This was thought to be in the context of either lacking or having limits to their health care insurance.82 Nevertheless, this relationship has been observed even when patients have access to universal health care insurance.86 Putrik and colleagues75 found that within such a health care system context, it was also patients’ decreased educational background that contributed to the lower likelihood of receiving a DMARD prescription. Having higher education was hypothesized to enable patients to gain better information about DMARDs and afford them better abilities to negotiate with their physicians about receiving DMARDs.75The association of lower access to DMARDs among those with lower SES was thought to be due in part to the cost of those medications. Lower incomes were thought to preclude the ability for patients to pay for them.89 Thus, it has been found that patients with lower SES were less likely to see rheumatologists.89 In the study by Yelin and colleagues,82 patients with lower SES were suggested to have access to federally run health centers that may have had fewer medical resources available to them. Moreover, physicians in those areas may have had less ability to access specialty care, like that provided by rheumatologists.82The finding that even living in an area associated with lower SES was associated with reduced access to DMARDS suggests that less household or neighborhood income may have served as a proxy for access to specialist care, which was thought to improve patients’ ability to access DMARDs.88 noted that these medications can be costly, with a single triptan pill costing up to $46 in the United States, for example. Bigal and colleagues62 wondered whether patients’ access to universal health coverage would mitigate the observed decrease in triptan use for migraines because patients’ income would potentially be a less important factor affecting its use. Socioeconomic factors like income and education have been suggested to be surrogate markers for patients’ access to care, and this may explain the observed relationship between lower SES and reduced triptan use.84 It was suggested that strategies to improve migraine management for patients without insurance coverage for medication or with lower SES include increasing their use of prophylactic medications rather than triptans and enhancing those patients’ pain self-management skills.88The cost of triptan medications was thought to explain the observed association of their reduced prescription and use among patients with lower SES and/or lack of insurance coverage. Wu and colleagues81 Other studies looked instead at household income; Stokes and colleagues78 additionally looked at whether households received other types of income support, such as housing support, food stamps, child support, and unemployment insurance. Wang and colleagues81 adjusted for household structure because they argued that such structure influences what resources are available to individual members of the household. A marginalization index was used in one study in order to gather information related to domains such as residential instability, material deprivation, dependency, and ethnicity.80 Alternatively, income was expressed in terms of how it related to federal poverty limits.89 Rather than using patient-generated data, some studies relied upon the use of census data in order to determine neighborhood income quintiles.76 It has been argued that a drawback to this is that such estimations may not reflect the true income for individuals in the study.81Income was measured in a variety of ways in the reviewed studies. In some studies, patients’ income was measured and then grouped into categories.72 found that the greatest predictor of patients’ use of nonopioid pain management modalities was having private health insurance. They argued that subsidization of such treatments is therefore important because patients may use medications such as opioids out of necessity rather than choice.72 Increased wealth that affords the ability of patients to pay for a greater variety of pain management options also is argued to facilitate other advantages, such as the ability to work fewer hours, or may be associated with occupations that support workplace accommodations or protect against the worsening or progression of chronic pain.14 Patients with lower SES may also experience greater barriers to accessing insurance coverage that extend beyond payment alone, such as navigating bureaucracies.24 Even with universal health care coverage systems or government-sponsored insurance programs, patients with lower SES were found to have decreased access to certain medication therapies; in some cases this was thought to be due to such systems as still not providing adequate coverage for therapies.82 As Booher23 pointed out, patients with lower SES “become caught in the vicious cycle of chronic pain leading to disability and poverty, and poverty worsening chronic pain.”Access to health care insurance was another surrogate measure of income that was employed by some studies because it was thought that this would have implications for patients’ abilities to access prescription medications. Indeed, studies confirmed this association. For example, Nielsen and colleagues88 Others looked at census data to obtain levels of education for ZIP code areas and used that information rather than details for individual patients.68 Putrik and colleagues75 suggested that a better way of looking at education would be to look at patients’ health literacy rather than looking at the level of education they had obtained because this might be more meaningful in terms of determining how or why level of education is associated with particular prescribing patterns.There was heterogeneity as well in the way in which level of education was measured in the reviewed studies. In some studies, it was viewed in a dichotomous manner looking at whether patients had less than or more than a college education or stratified in terms of the highest level of education obtained.373 Green and colleagues15 noted that decisions about pain management are affected by characteristics of patients, health care providers, the clinical practice environment, and the overall health care system in which pain care is provided. Physicians may “unconsciously consider judgements beyond clinical factors in their decisional processes.” This is especially true for conditions like chronic pain, argued Anastas and colleagues,59 because of pain’s “subjective nature” and “clinical uncertainty.”(p772) As they put it, “Providers’ attitudes may ‘fill in the gaps’ of insufficient or ambiguous information, resulting in systematic differences in chronic pain care across race and SES groups.”59(p772)The social context in which chronic pain clinical encounters take place as well as both implicit and explicit biases held by physicians can influence prescribing patterns and lead to disparities in pain management.374–377 For example, compared to the experience of White patients, Black patients’ pain has been shown to not be as aggressively assessed or treated, they are less likely to be referred to pain specialists,377 and they are more likely to be required to provide urine drug screens.376There is extensive literature demonstrating bias in how health care providers treat patients from specific ethnocultural backgrounds.79 suggested that inequities in the delivery of pain care may not be due to ethnocultural status alone and that SES is implicated as well. Less common are such studies looking at bias in how patients with lower SES have been treated,79 but the studies that have been done that specifically look at the way in which variability in health care provider and patient characteristics affects chronic pain management decision making have confirmed that lower SES can lead to inequities in pain care.379 Patients with lower SES and chronic pain have been viewed by health care providers to be less competent and compliant in the use of medications and other multidisciplinary therapies for pain.369 They have been thought by physicians to have less self-control over medication use with a greater propensity to misuse opioids and so studies have found that physicians disproportionately require them to complete opioid contracts compared to patients with higher SES.380 Patients with lower SES have been considered by health care providers to be more “demanding,” and their pain has been referred to in “dehumanizing” ways. Tamayo-Sarver and colleagues79 wrote that SES was associated with “physicians’ perceptions of patients’ abilities, personalities, behaviors, and role demands” and that physicians “may treat patients preferentially if there is less social distance between them.”(p1245) Green and colleagues15 suggested that more research is needed to better understand the factors that “systematically influence” physicians’ decisions regarding pain management.(p286)Tamayo-Sarver and colleagues382 Poorer communities are less likely to be situated in proximity to pain clinics, making it more challenging for their residents to access them.384 Moreover, access to medications in communities associated with lower SES has been found to be an issue because pharmacies in those areas may not have sufficient supplies of medications compared to pharmacies located in communities with higher SES.382 Morrison and colleagues385 found that disparities in supply were seen when looking from an ethnocultural perspective as well. Even after adjusting for rates of crime, pharmacies in New York City in Hispanic and African American neighborhoods were less likely to supply opioids compared to those located in White American ones.385Characteristics of the communities in which patients reside also affect their ability to access prescription medications for chronic pain. Residing in communities with lower SES has been found to cause increased exposure to violence, psychosocial distress, and social isolation and, thus, to increased risk factors for the development and furtherance of chronic pain.77 identified that there was a decline in the number of individuals receiving opioids during the years 2013 and 2016 and suggested that this may reflect changes in physician prescribing practices as awareness of the opioid epidemic grew and as Centers for Disease Control and Prevention guidelines about reducing opioid use were developed. Nevertheless, they still found that there was an association between SES and the likelihood of being prescribed opioids for chronic pain management.77Physician prescribing practices for chronic pain management are influenced by practice guidelines. In their study including in this review, Stokes and colleagues363 noted, “Race and socioeconomics are entangled constructs sometimes interacting and sometimes acting individually”(p1160) and thus they argued that SES and ethnicity cannot be used interchangeably. Patients considered to be ethnic minorities in North America have been found to have a disproportionate burden of chronic pain and lack of access to pain management.382 For example, African Americans have been found to have increased chronic pain prevalence, intensity, and pain-related distress, disability, and interference of function compared to other ethnic groups.386–388 Moreover, they have been found to have increased exposures to risk factors for the development of chronic pain and to be offered less comprehensive pain management options.382 The etiology of this is multifaceted, including mistrust of the health care system at the individual level363; decreased access to health care resources such as therapies, primary care physicians, and pain specialists at the health system level382; and negative stereotypes and discrimination at the societal level.389 It has therefore been suggested that research related to the effects of SES on access to pain care should also consider patients’ ethnocultural status and recognize that socioeconomic advantages and disadvantages are not uniform across ethnocultural groups.361 As Riskowski28 pointed out, patients’ income, education, social status, and ethnicity may each contribute in some way to “the development of pain or in the management of pain, or lack thereof … these factors together can create access to vital, influential, and extensive resources and opportunities to impact health and health behaviors.”(p1517)In this scoping review, SES was looked at from the perspective of income and education but there are other components of SES that could be investigated. Similar relationships between SES factors such as level of education and income and chronic pain have been found for ethnicity. As Fuentes and colleagues7 pointed to Crenshaw’s390 theory of intersectionality as providing a useful way of depicting the manner in which the variety of factors that contribute to patients’ social circumstances and identities interact to affect their experiences with chronic pain. They described that patients’ life experiences and identities “interact to position an individual along a specific trajectory that may confer a position of advantage or disadvantage for health” and “can factor into the creation and maintenance of chronic pain disparities.” Bonathan and colleagues14 outlined in particular how lower SES and chronic pain are interconnected:pThe consequences of feeling socially inferior, living in a less socially cohesive neighborhood with a more imminent sense of threat, combined with poorer education and, therefore, poorer job opportunities are likely to interact with the psychological factors known to increase the risk of chronic pain … financial restrictions also constrain coping strategies and since some coping is consistently associated with greater disability, this is a self-maintaining process. Educational level may also influence choice of strategies.Brady and colleaguesTherefore, to better understand why chronic pain is not addressed in the same manner for all patients, an understanding of the “conditions in which people are born, grow, live, work, and age, and the inequities in power, money, and resources that are responsible for disparities in health outcomes” is necessary.86 Others used cross-sectional surveys that often use patient self-report in order to acquire date. Such studies are therefore associated with potential recall bias and reporting inaccuracies.76 Information may not have been verified by review of charts or provider information.84 Different studies adjusted for different variables when looking at pain-related outcomes. For example, Chuang and colleagues63 controlled for potential confounders including depression, pain severity, pain interference, global physical and mental functioning, and demographic characteristics, whereas Grol Prokopczyk67 controlled for age, sex, race/ethnicity, and marital status. Second, the retrospective nature of most of the reviewed studies meant that they could only show associations and could not determine causality.63 Third, studies that looked at prescribing patterns may be inaccurate, because reports based upon self-report may not reflect what physicians recommended. Additionally, the provision of a prescription does not necessarily mean that it was filled67 or that medications were actually taken by patients.68 There may have been reasons why patients were not provided with certain treatment options, and this was often not reported in studies .67 Fourth, various elements of SES were at times grouped together. For example, Nampiaparampil and colleagues71 grouped lower SES related to income and education together with ethnicity and so this would make distinguishing the effects of ethnicity itself from SES challenging.The results of this review must consider the limitations associated with the reviewed studies. First, there was heterogeneity among the studies from several perspectives. As noted earlier, studies used different ways of measuring SES, in terms of both income and education. Studies used various methodologies; some used data from administrative databases, which can be associated with concerns about the accuracy of diagnoses used and thus the manner in which cases were selected.23 used key words such as “socioeconomic status” and “chronic pain” but noted that this may have led to missing some studies; this limitation applies to this scoping review as well. A variety of databases that include publications related to medicine, nursing, public health, sociology, and pain were used in order to ensure that as many relevant studies were found as possible. However, limiting the search to particular databases may have led to missing studies. Additionally, the factors that lead to a patient being prescribed a specific medication for chronic pain management are known to be complex and involve a variety of steps.84 For example, patients must be able to access a health care provider, receive a diagnosis, receive a prescription, fill that prescription, and then take that medication.84 There are factors associated with SES that can influence each of these steps. This scoping review’s focus on patients being prescribed or taking a medication therefore misses some of these other factors. Not all types of chronic pain conditions were considered in this scoping review, and so its findings cannot be generalized to chronic pain conditions beyond those described in the inclusion criteria. A final limitation is that this review only includes articles that were published in English. Despite these limitations, we identified a relatively consistent pattern between SES  and its association with chronic pain management using prescription medications.There are limitations associated with this scoping review as well. BooherThis scoping review provides insight into the complex interactions between SES, specifically income and education, and access to pharmacological treatments for specific chronic pain conditions. The studies examining this topic are heterogenous in terms of how they considered income and education, the methods they used, and the conditions and medications they studied. Nevertheless, an association was found such that patients with lower SES typically do not receive equal prescription medicine opportunities for their chronic pain conditions.15 recommendations about how to address the gap in knowledge related to ethnicity and pain care can be applied in considerations of how to address this gap related to SES. At the level of the patient, more knowledge is needed from the perspective of patients with chronic pain and lower SES regarding their needs, the challenges they experience obtaining pain management related to their income and education status, and their goals and expectations for treatment. Although this review focused on income and education as they pertain to SES, other areas that require attention are the disparities in access and care that patients receive based upon other factors, such as gender, ethnicity, and language. At the provider level, more research is needed to understand how patients’ income and education affect physicians’ decisions about chronic pain management and about stereotyping and biases that may be involved. At a broader level, more research has been recommended to understand how patients’ income and education intersect with various other social determinants of health to create, influence, or exacerbate chronic pain management disparities.Further research is required to better understand hpw lower SES is associated with disparities in the provision of pharmacological pain management with the aim of reducing the magnitude of such disparities. Green and colleagues’391 Health care providers have been found to overestimate patients’ understanding of clinical information.392 It has been suggested that providers use literacy-dependent teaching methods to provide information using a variety of modalities.393–396 This would help promote shared clinical decision making.393 With regard to addressing issues related to patients’ income, this could involve health care providers having open discussions with patients about the costs of pharmacological therapies.397 Indeed, there is evidence to suggest that many providers consider it their responsibility to have such conversations with patients.399 Among the suggestions that Kolhatkar and colleagues397 have for prescribers to improve medication affordability are their “staying up to date on drug costs, prescribing the most cost-effective alternative, frequently reviewing medication prescription regimens for opportunities to deprescribe and prescribing generic drugs.”(pE549) It is important that health care providers be vigilant in considering the various factors that influence their prescribing practices. Physicians should be encouraged to examine their own implicit assumptions and behaviors toward chronic pain.59 Moreover, it has been suggested that clinicians consider as well the financial conflicts of interest that may influence their prescribing of more expensive medications.400 In accordance with the recommendations of the Canadian Pain Task Force,12 other prescriber-level strategies include improving health care provider education of chronic pain as well as ensuring that its assessment occurs within a biopsychosocial framework that considers patients’ social determinants of health. Using a biopsychosocial approach to chronic pain conditions may assist in addressing the inequitable prescribing patterns among physicians based on a patient’s socioeconomic status because it would involve understanding the association of the patients’ pain with different aspects of their lives and vice versa. Understanding of patients’ socioeconomic situations can help better identify care options that are appropriate for them.Addressing disparities in chronic pain care will similarly require a multitiered approach, with particular strategies at the level of the health care provider. With regard to addressing issues related to patients’ education, this could involve improving provider education concerning patients’ health literacy.14 First, expansion of insurance coverage for pain therapies is required. Programs in the United States such as Medicaid and those provided by the Veterans Health Administration have been shown to significantly improve patients’ access to pharmacological therapies and increase medication treatment adherence.401–404 It has been suggested that further reducing or eliminating any co-payments that patients need to provide could further improve access to care for patients with lower SES.406 In Canada, the Canadian Pain Task Force12 recommends the expanding of patients’ access to pain treatments under provincial health care coverage and working with private insurers to incentivize expanded coverage of pain management options. Some provincial governments have endorsed improving patients access to currently non-insured nonpharmacological therapies for chronic pain.407 Previous studies have demonstrated that universal access to health insurance is not adequate to achieve total equity in access to appropriate pain management treatments.86 Therefore, it has been suggested that programs of universal coverage of prescription medications focused on equity should be developed to ensure that medications can be provided to patients based upon their needs.409 Second, the creation of national clinical guidelines to facilitate “evidence-informed, trauma-informed, equity-oriented, and biopsychosocial management of chronic pain across health care settings” has been recommended. This sort of advocacy has been done by clinical organizations with the assistance of experts in health policy, pharmacoeconomics, behavioral sciences, clinical care, and the pharmaceutical industry in order to support the development of national policies to increase the affordability of medications.410 The importance of such health system reforms is made clear, as Brady and colleagues7 noted that “recognizing chronic pain not only as a physical, socioeconomic or psychological problem but as an interaction between social class, migration class, gender, ethnoculture, and the health system encounter would facilitate framing of health disparities as a function of the system, rather than a responsibility of … specific communit[ies].”(p442)Higher-level strategies could focus on health care system reforms to improve patients’ access to evidence-based pharmacological, physical, psychological, and spiritual treatments for chronic pain.


Most women of reproductive age suffered from the primary dysmenorrhea (PD). Up to date, most studies on the etiology of dysmenorrhea focused on endocrine factors while ignored the effect of spino-pelvic bony anatomy on uterus. In this study, we innovatively shed light on the relationship between primary dysmenorrhea and sagittal spino-pelvic alignment.120 patients diagnosed with primary dysmenorrhea and a control group of 118 healthy volunteers were enrolled into this study. All subjects received the standing full-length posteroanterior plain radiography to evaluate the sagittal spino-pelvic parameters. The visual analog scale (VAS) was used to assess pain rating of primary dysmenorrhea patients. Analysis of variance (ANOVA) or Student's t test was performed to measure statistical significance between differences.P<0.05). Furthermore, in PD group, the PI and SS was significant different between mild pain group and moderate pain group (P<0.05) and there was a significant negative correlation between pain rating and SS. From the perspective of sagittal spinal alignment, the majority of PD patients were classified with Roussouly type 2, meanwhile most normal people were classified with Roussouly type 3.There was a significant difference in pelvic incidence (PI), sacral slope (SS), lumbar lordosis (LL) and thoracic kyphosis (TK) between PD group and Normal group (Sagittal spino-pelvic alignment was related to primary dysmenorrhea symptoms. Lower SS and PI angles may contribute to a worsen pain in PD patients. Primary dysmenorrhea (PD) is one of the most complained diseases among adolescence and childbearing age female. Women of reproductive age are reported to suffer from dysmenorrhea to the extent of 16%-91%, with a higher incidence in adolescents observed in 56.1% to 93.0% . In addiThe etiology of PD is not fully elucidated. Since no organic lesion was detected in primary dysmenorrhea, there were various possible pathogenic factors reported in the previous literature such as overproduction of uterine PGs, psychological factors, vasoconstriction caused by the increase of vasopressin level and adverse uterine position .However, patho-physiologic rather than anatomical factors are more stressed in the present literature discussing the etiology of PD. Since Roussouly etal. reported the classification of the normal variation in the sagittal alignment of the human lumbar spine and pelvis , the spiA retrospective study design was conducted to investigate the relationship between spino-pelvic alignment and primary dysmenorrhea.We enrolled 120 patients (24.7 ± 3.8 years old) diagnosed with primary dysmenorrhea and a control group of 118 healthy volunteers (23.5 ± 3.6 years old) without any uterine diseases or musculoskeletal disorders such as low back pain in the outpatient clinic of our department of West China hospital from July 2018 until May 2021. The exclusion criteria were: 1. Scoliosis or any congenital deformity of lumbosacral segment; 2. history of spinal or abdominal surgery; 3. smoking; 4. history of anxiety, depression, or severe mental disease; 5. obesity, defined as body mass index (BMI) > 25.0; and 6. history of taking oral contraceptive pills; 7. history of delivery.; 8. history of gynecological disease. All experimental procedures and methods were approved by the research ethics committee of the West China hospital and provided informed consent. All protocols were conducted in accordance with the research principles set forth in the Declaration of Helsinki.The visual analog scale (VAS) was used to assess lower abdominal pain of primary dysmenorrhea. And the patients were divided into three groups: (1) mild pain (1–3 scores), which can be tolerated and have little affect on daily life and sleep quality; (2) moderate pain (4–6 scores), evident pain affecting sleep but tolerable after simple treatment; (3) severe pain (7–10 scores), progressively intensive pain that is intolerable and requires specialized treatment for its relief.All subjects underwent standing full-length posteroanterior plain radiography. All radiological parameters were measured by two attending spinal surgeons, and the average values were adopted. The radiographic measurements included the following: lumbar lordosis (LL) was measured as the angle between the upper end plates of L1 and S1; Thoracic kyphosis (TK) was measured as the angle between the upper endplate of T5 and the lower endplate of T12; C7-sagittal vertical axis (SVA) was measured as the distance between the C7 plumb line and the posterosuperior border of S1; pelvic incidence (PI) was measured as the angle between a vertical line perpendicular to the sacral endplate at its midpoint and a line connecting the midpoint of the sacral endplate and the midpoint of a line connecting the centers of the two femoral heads; sacral slope (SS) was measured as the angle between the horizontal plane and the sacral plate . And thet test was performed to measure statistical significance between differences, correlations were assessed using Pearsons correlative analysis, and P < 0.05 was considered statistically significant.Statistical analyses were performed using GraphPad Prism . The measurement data are expressed as mean ± standard deviation. Analysis of variance (ANOVA) or Student's P<0.05). The PI of PD group was 47.78 ± 5.60° vs. 52.38 ± 4.63° of Normal group (P = 0.000), the SS of PD group was 36.61 ± 7.57° vs. 39.61 ± 5.47° of Normal group (P = 0.0006), and the LL of PD group was 44.19 ± 7.07° vs. 48.44 ± 3.90° (P = 0.000), the TK of PD group was 20.08 ± 8.00° vs. 23.34 ± 7.19° of Normal group (P = 0.001). Whereas, there was no significant difference in SVA between PD group and Normal group the SVA of PD group was 11.35 ± 5.08 mm vs. 11.19 ± 5.41 mm of Normal group (P = 0.814).The parameters of lumbar-pelvic alignment between PD and normal groups were shown in P = 0.046), however, there was no significant difference between moderate pain group and severe pain group. The SS was also significant different between mild pain group and moderate pain group , whereas, no significant difference was found between moderate pain group and severe pain group . For LL,TK, and SVA, none of these differences were found statistically significant. The LL in each group were 45.51 ± 6.68°, 43.73 ± 6.93° and 43.30 ± 9.64° . The TK in each group were 21.41 ± 4.38°, 19.34 ± 8.83° and 21.63 ± 10.55° respectively . The SVA in each group were 10.90 ± 5.30 mm, 11.74 ± 4.92 mm and 9.68 ± 5.83 mm . The results above were illustrated in The PD patients were divided into three groups according to VAS scores. As shown in r2 = 0.031, P = 0.054), LL ,TK  and SVA , while a significant negative correlation between pain rating and SS . The linear regression of correlation analyses above were shown in The correlation analyses were carried out to assess the correlation between pain rating and each spino-pelvic alignment parameters above. In summary, there were no significant correlation between pain rating and PI (The PD patients and normal volunteers’ radiographic data were then classified according to their Roussouly spine classification. The Roussouly type 1 patient number of PD group and normal group were 19 and 11 respectively. As for Roussouly type 2, the patient number of PD group and normal group were 41 and 19. And the Roussouly type 3 patient number of PD group and normal group were 33 and 58, the Roussouly type 4 patient number of PD group and normal group were 27 and 30. The distribution of the patients number of each Roussouly type was shown in To further investigate the correlation between Roussouly classification of PD patients and pain rating, the different pain rating PD patients were sorted by Roussouly spine classification type. There were 2 mild pain patients, 13 moderate pain patients and 4 severe pain patients classified with Roussouly type 1. And 2 mild pain patients, 37 moderate pain patients and 2 severe pain patients were classified with Roussouly type 2. While 15 mild pain patients, 16 moderate pain patients and 2 severe pain patients were classified with Roussouly type 3. Besides, 14 mild pain patients, 12 moderate pain patients and 1 severe pain patients were classified with Roussouly type 4. The distribution of the PD patients with different pain rating classified with Roussouly type was shown in In recent years, the sagittal spino-pelvic alignment or balance had received more and more attention from various scholars and spine surgeons. Several studies have investigated the importance of sagittal spino-pelvic alignment in spinal disorders such as lumbar spondylolisthesis –14, adolThe human species is characterized by bipedal walking, which has the advantage of freeing up upper limbs for other tasks, but at the expense of a more unstable overall balance. Indeed, other primates, unlike humans, move on all the four limbs. Their spine presents a single thoraco-lumbar curvature in kyphosis which provides more space for pelvic and abdominal organs and a better global sagittal balance . HoweverOur results firstly indicated that the PI, SS and LL in PD patients were significant lower than those in normal people . In addiAccording to the results we found and the hypothesis raised above, an implication of this is the possibility that a lower sacral slope and pelvic incidence may lead to a related smaller pelvic space and a retroversion of uterus. The excessive retroversion could lead to outflow obstruction of menstrual blood and uterine secretions, resulting in local inflammatory reaction, so as to stimulate uterine contraction and cause dysmenorrhea. On the other hand, a higher SS and PI could make uterus a relatively anteversion position, leading to a smooth outflow of menstrual discharge through vagina and therefore relieving the pain. The possible pathophysiological mechanisms were shown in However, this study still has some limitations. The number of patient samples was limited in this retrospective study, a larger sample size was required to fully validate the hypothesis above. Furthermore, limited by the current gynecological ultrasound and abdominal CT examination require supine position, we were not able to assess the patients’ exact uterine position in a standing position, thus could not precisely verify the correlation between the spino-pelvic alignment parameters and pelvic organ position.In summary, we first reported the relationship between sagittal spino-pelvic alignment and primary dysmenorrhea. In PD patients, worsening pain may be correlated with lower SS and PI angles, which provided a fresh and unique perspective on the cause of primary dysmenorrhea.


Chronic low back pain (CLBP) is one of the most resistant pain conditions and is often combined with psychoemotional disorders [1].To analyze the frequency of prescribing adjuvant analgesics among patients with CLBP by specialists of the outpatient department and specialized pain clinic.The prospective study included 269 patients (group 1) with CLBP treated in an outpatient department and 253 patients (group 2) of specialized pain clinic. We analyzed gender, age, duration, and severity of pain , frequency of prescribing anticonvulsants and antidepressants, as well as their combination in both groups. The data were analyzed with IBM SPSS Statistics.Among the patients of both groups, women predominated (65.3% in group 1 and 57.2% in group 2). The average age was 61.8±14.5 and 58.9±12.7, in the first and second groups, respectively. The disease duration was longer in group 2 . Pain intensity was comparable in both groups . Antidepressants there were prescribed 16.1% and 52.9%, p<0.05, anticonvulsants - 18.8% and 33.2 %, p<0.05, their combination - 2.2% and 13.8%, p<0.05 in the first and second groups, respectively.Adjuvant analgesics are more often prescribed to patients of specialized pain clinics. It may be associated with more severe descriptions of chronic pain syndrome, as well as insufficient awareness of modern approaches to the management in this category of patients by specialists in primary health care. References: 1.Zagorulko, Medvedeva Russ Pain J. 2019


The treatments were performed 5 days a week (from Monday to Friday) for two weeks. Treatment progress was measured by the visual analogue scale (VAS) for rest pain, night pain, and pain during activity; the Laitinen Pain Scale (LPS); and hand grip strength (HGS) before and after the treatment, as well as after 3, 6, 12, and 24 weeks. The reduction of pain (according to the VAS and LPS) and increase in the functional condition (according to the HGS) were observed in all HVES patients in the short- and long-term observation. Therefore, the HVES in treatment of LE was found to be effective and safe.The available publications describing the beneficial effects of electrostimulation does not unequivocally confirm the clinical utility of high-voltage electrical stimulation (HVES) in the treatment of the lateral epicondylitis (LE). The aim of this study was the estimation of the effect of HVES on pain intensity and functional efficiency, both in the short and long term in patients with LE. The trial was registered by the Australian and New Zealand Clinical Trials Registry (ACTRN12621001389897). There were 58 patients allocated into two groups: the HVES group , treated with HVES , and the NORM group ( Treatment of the lateral epicondylitis (LE), also known as a tennis elbow (TE), can be divided into conservative treatment, mainly aimed at reducing pain, and surgical treatment, when conservative therapy is unsuccessful. LE is manifested most often by pain in the elbow area and a reduced in grip strength. It affects 1–3% of the adult human population between the ages of 40 and 60 ,6,7.The fast development of medical devices, the low cost of treatments, and rarely occurring side effects are the reason that physical methods are more often used in the treatment of enthesopathy of the lateral humeral epicondylitis, which shortens the time of treatment and can be used instead of pharmacological treatment or even surgical treatment ,5,6,7,8.The effectiveness of physical methods was confirmed by a large number of research works using, e.g., high- and low-intensity laser therapy (HILT and LILT), shock wave therapy (SWT), ultrasound therapy (UD), kinesiotaping (KT), and electrostimulation (ES). The review of the literature on the treatment of LE shows great interest in shock wave therapy (SWT), and there are also reports in the literature on the use of UD, LILT, and KT . ResearcTo assess the outcome of therapy, researchers most often use the VAS scale, grip strength tests, and various functional tests: the Duruöz Hand Index (DHI) , PatientHigh-voltage electrostimulation (HVES) is a therapeutic current consisting of a monophasic double impulse (there are single- and two-phase impulses), the voltage of which is usually in the range of 100–500 V. The pulse duration is between 5 and 200 µs, and the frequency is in the range from 1 to 125 Hz. The duration of the double pulse is about 1% of the period, while the pause time is 99% of the period. Hence, the duty cycle factor can be determined, i.e., the ratio of the pulse duration to the pulse period, which is equal to 0.01 for this waveform  9,10,11,14. The In general, the availability of publications describing the beneficial effects of electrostimulation in the treatment of tennis elbow is low. Currently, there are a few scientific papers that describe the use of electrostimulation in most cases, in combination with other physical therapy in LE. However, these trials do not include the effect of HVES in the TE problem.Radpasand et al.  used HVENourbakhsh et al.  used noxChesterton et al.  presenteA similar study was presented by Wend et al. . They inPołtawski et al. tried to find the optimal parameters of microcurrent therapy in reducing pain intensity, improving the function and strength of the clamp. In the first trial, they had two groups of patients and used a monophasic current of 50 and 500 µA for 3 weeks, once a day for 99 min for 21 days. The second trial was also divided into two groups, for the first one, a monophasic current of 40 µA once a day for 6 h and for 3 weeks was applied, which gave the total duration of treatments 189 h. Moreover, in the second group, a regulated current of 40–500 µA was applied for three weeks, except that in the first week, it was applied three times a day for 30 min for 5 days; in the second week, twice a day for 30 min for 5 days; and in the third week, once a day for 30 min for 5 days . The authors performed assessments after 3, 6, and 15 weeks of treatment. The best results were obtained in the first trial for the first group, where a monophasic current and a constant intensity of 50 µA were used . These results were maintained 15 weeks after the end of treatment .Full methodological descriptions, electrical parameters, inclusion and exclusion criteria, randomization, and analysis of early later results in cited manuscripts are not always provided.Therefore, the present study was proposed with the objective of evaluating the effects of HVES on pain and range of hand grip strength in LE.The purpose of this study was to investigate the efficacy of high-voltage electrical stimulation in patients with chronic lateral epicondylitis of the humerus. The effectiveness of HVES use was assessed by examining pain intensity  and functional efficiency (according to the HGS), both in the short and long term.A single-center  study was conducted from December 2014 to November 2016. The study was approved by the Bioethics Committee of Bioethics Commission of the Medical University of Silesia in Katowice, Poland (KNW/0022/KB1/158/10). All patients provided signed informed consent for this project. All clinical investigation was conducted according to the principles in the Declaration of Helsinki. The study was performed according to the requirements of the Consolidated Standards of Reporting Trials (CONSORT) statement  21]. Th. Th21]. n = 29, 17 females and 12 males) with a mean age of 49.9 ± 11.0 years, and NORM  with a mean age of 48.0 ± 12.6 years. The average duration of disorder in the HVES group was 12.7 ± 15.6 with a median of 4 months (range: 1–70). In the NORM group, the patients did not suffer from chronic lateral epicondylitis (LE) of the humerus. Patients from the comparative groups were homogeneous in terms of gender, age, height, weight, and BMI  participated, with a mean age of 48.9 ± 11.7 years (range: 20–72) and a median of 51 years (quartile range: 40–58). Patients were placed into two comparative groups: HVES .On the basis of the results of the pilot study, we estimated the sample size necessary to demonstrate a statistical significance of We included patients with LE qualified by a neurologist, a radiologist, and an orthopedist in order to confirm the disease. Each patient had an X-ray examination of the elbow joint in two anterior–posterior (AP) and lateral projections before the procedures were started. Patients with permanent pain in the lateral epicondyle for more than one month in one upper limb were qualified for the study.The exclusion criteria for patients in the HVES group were as follows: cervical and thoracic spinal pains, fractures, golfer’s elbow, pregnancy, having a pacemaker, rheumatic dis-eases, cancer, cardiovascular diseases, metal implants, corticosteroid injections carried out within the last 6 weeks, diabetes, skin inflammation, and being under 18 or over 75 years of age.Healthy persons were enrolled in the NORM group by a neurologist. All patients had a physical and medical examination. We included patients with lack of pain and correct mobility in the upper limb. All persons subjected to examination and measurements were in good general condition, not requiring therapeutic intervention for any other reason.The exclusion criteria for patients in NORM group were the same as in the HVES group.In the HVES group, all the treatments were performed with the Ionoson Physiomed PMD–91220 high-voltage electrical generator .Before performing each individual procedure for a patient, the stimulation current was checked for the generated electric current waveform in a 10 kΩ resistor connected in parallel with the generator (Ionoson Physiomed PMD–91220) and the oscilloscope  a.The current waveform of treatment consisted of double monophasic pulses with a total duration of 200 µs and a frequency of 100 Hz, with a voltage amplitude of 100 V. Regulation of the root mean square current of the generator was from 18 to 25 mA (average 21.5 mA) and was adjusted individually to each patient depending on their sensitivity to pain tolerance. The stimulation was performed with a current that did not cause any motor effects, only a tingling sensation. A conductive silicone electrode (Physiomed Elektromedizin) with dimensions of 8 × 6 cm and an area of 48 cm² was used. The active electrode (anode) was placed on the lateral epicondyle of the diseased upper limb. The passive electrode (cathode) was placed on the forearm of the sick upper limb. The electrodes were placed in a viscose casing soaked in physiological saline b.The treatments were performed 5 days a week (from Monday to Friday), every day for a period of two weeks. Each treatment lasted 50 min. The procedure was performed in a sitting position, the patient’s arm was abducted, the elbow joint was bent at a 60-degree angle, the forearm was pronated, and the arm and forearm were supported by the chair’s armrest b.In the NORM group, no physical treatments and stabilization training were applied. Hand grip strength was measured at the same control intervals as for the HVES group.The therapeutic outcome measurement progress of the Hydraulic Hand Dynamometer Analogue , the VAS analogue scale, and the Laitinen Pain Scale (LPS) were used before treatments; immediately after treatment; and a 3, 6, 12, and 24, weeks follow-up.The HHDA was used to analyze an average hand grip strength parameter, including the strength of the flexor muscles of the fingers of the hand, resistance flexion in the wrist, and resistance extension in the wrist.The VAS was used to measure level of rest pain, night pain, and physical activity pain. The score of 0 was assigned for no pain, and the score of 10 was assigned for the strongest pain.The LPS was used to assess 4 indicators: pain intensity, frequency of pain occurrence, use of analgesics, and limitations of mobility. It contains four areas to be assessed on a scale from 0 to 4, where the number 0 means no problem in a given area, and the number 4 means its maximum degree. The maximum score for four indicators is 16 points, with the lower the LPS score, the better it is for the patient.The normality of the distribution of the data was tested by means of the Shapiro–Wilk test. To compare variables in both groups of patients, a chi-squared test of independence (the highest level of reliability) and the Mann–Whitney U test were used. To compare the measured values  obtained before; immediately after; and at 3 weeks, 6 weeks, 12 weeks, and 24 weeks after therapy with the HVES, the non-parametric Friedmann ANOVA test and post hoc Dunn–Bonferroni test were used.The reliability hand muscle strength was assessed by the intraclass correlation coefficient (ICC). ICC values and their 95% confidence intervals were calculated on the basis of a values of six Hydraulic Hand Dynamometer Analogue recordings .p = 0.05.All statistical analyses were performed using the STATISTICA software  and PQStat software . The level of statistical significance was assumed at In total, 58 patients were enrolled. All patients were monitored for 180 days after therapy. The treatment was effective for all patients.p < 0.001), but post-hoc comparisons showed that there were no statistically significant differences (0.103) only before and immediately after the study. Moreover, after 3, 6, 12, and 24 weeks after therapy, the differences in hand grip strength were statistically significant ; the reliability of the measurement was ICC = 0.991 for six time intervals. Similar reliability results were obtained in resistance wrist flexion strength  and resistance extension in the wrist strength  measurements.The reliability of measurements of the hand grip strength, resistance wrist flexion strength, and resistance extension in the wrist strength in the NORM group was checked using the intraclass correlation coefficient (ICC). The analysis carried out for the measurements of the hand grip strength showed a significant agreement of the measurements (p < 0.001) on the VAS scale. Rest pain was gradually reduced to 0 points (range 0–3) 24 weeks after treatment (p < 0.001) (p < 0.001). Night pain and pain during activity were gradually reduced. Interestingly, the maximal reduction of pain  was observed immediately after treatment   before to 0 points (range 0–7) after treatment (< 0.001) a. The sa< 0.001) b and pai< 0.001) c. In boterences) .p < 0.001). The LPS median value decreased from 7 points (range 4–12) before treatment to the value of 2 points (range 0–9) after treatment (p = 0.002). Moreover, in 3, 6, 12, and 24 weeks, the LPS values were gradually decreased in time to 0 points (range 0–4).The situation was very similar for the assessment of the LPS d. The FrIt is important that we do not see any deterioration in the hand grip strength, VAS scale, and LPS scale values in long-term observations. Moreover, significant statistical decrease during long-time follow-up indicated a positive analgesic effect of HVES therapy.The analgesic effect of electricity was known and used in the treatment of many diseases, mainly those related to back pain, e.g., lower back pain ,24. The In the available literature, several studies confirm the analgesic effects of electric current in treatment of LE ,18,19,20There are no scientific reports on the effectiveness of HVES in the treatment of LE with the exception of one. Nevertheless, Radpasand et al.  used HVEThe electric current waveform used in this protocol was established on the basis of experience in the use of the analgesic effect of the current. In various reports ,18,19,202 (6 × 8 cm). Patients were treated for 50 min per visit for 2 weeks from Monday to Friday .In our study, we used twin-peak monophasic electric current waveform with very short pulse duration of 200 μs, frequency of 100 Hz, and voltage amplitude of 100 V. The current intensity was used in the range from 18 to 25 mA (average 21.5 mA) at the level adapted to the patient’s tolerance. In our study, we used rubber electrodes with a surface area of 48 cmRadpasand et al.  used HVEThere are differences between our parameters of the applied current for electrostimulation and those used by other scientists. The frequency of the current closest to the one used by us is noted in Radpasand et al.  and ChesA single procedure lasted from 20 min to 6 h, and the entire treatment took up to 3 weeks . This is similar to our protocol.The results of pain reduction in our research are consistent with other scientific reports on the use of electrostimulation in reducing pain. It can be seen that after 2 weeks of using pain relief therapy (immediately after treatment), there was a significant reduction in the value of rest pain, night pain, and pain during activity.In all the works cited by us, the analgesic effect of electrostimulation was observed. For subjective pain assessment, Radpasand et al.  and WendA review of the literature shows that the researchers present hand strength results as a promising tool. Radpasand et al. , PołtawsAll studies show a significant difference of the results obtained in the questionnaires for assessing the effectiveness of therapy. Patient-rated LE evaluation PRTEE was used to assess pain and functionality of patients with tennis elbow  and answer to the question: which method of treatment is more effective?HVES treatment reduces pain and increases functional conditions in relation to baseline. The HVES method is effective and safe for patients with LE, which was confirmed by short- and long-term observations.


Spinal injection has been an accepted part of conservative therapy for degenerative diseases. The drugs used can cause side effects and severe complications. The aim of this study was to determine the occurrence of general side effects (GSE) and complications when performing consecutive different types of spinal injections and to evaluate pain reduction.Prospective data evaluation of patients with degenerative spine disease at hospital admission, discharge, and six and 12 weeks after discharge. All patients received a specific injection protocol depending on their symptoms and radiological findings. The injections performed were dorsal sacroiliac joint injections, perineural injections, epidural interlaminar and epidural periradicular injections, and facet joint injections. Potential complications were categorized and recorded as GSE and complications. In addition, the Numerical Analog Scale (NAS) for pain, the Oswestry Disability Index (ODI) were evaluated.p < 0.001), but relapse occurred at the 12-week follow-up.Forty-eight patients were enrolled. There were 282 spinal injections performed. A total of 131 common treatment-related events were recorded. Depending on the type of injection, transient pain at the injection site (32.4–73.5%), radiating pain (9.4–34.7%), and nerve root irritation (2–18.4%) were the most common. One complication with postpuncture syndrome occurred with epidural-interlaminar injection. No persistent neurologic deficits occurred. The highest rate of GSE was observed with periradicular injections (relative frequency (RF) = 0.8), followed by epidural-interlaminar injections (RF = 0.65), least frequently with FJ injections (RF = 0.32). From the time of admission to discharge, NAS scores were significantly decreased and ODI score significantly improved at discharge (Various consecutive spinal injections for conservative treatment of degenerative spine diseases are safe and lead to a decrease in pain and improvement in quality of life. GSE are common, but not persistent. Although complications are rare, they can have serious consequences for the patient. Injection of the spine has been an integral part of conservative therapy for degenerative diseases for several years . This maDue to crystalline suspension, ischemic neurological injuries may occur in the worst case . AllergiThis prospective study aimed to determine the overall risk for the occurrence of general and specific complications when performing consecutive different types of spinal injections in the treatment of degenerative spinal disease. The primary study objective was to record general side effects and specific complications due to spinal infiltrations. The secondary study objective was to record pain reduction and change in quality of life due to treatment.Hospitalized patients with exacerbation of acute and chronic pain associated with degenerative spine disease who could not be adequately treated as outpatients were enrolled in this prospective study at a single spinal center. The treatment plan for the planned injections was determined by an experienced spine surgeon. Generally, no injection technique type was performed twice on the same patient. All patients were treated per day with a single type of injection in the area of the lumbar spine. The total number of injections that were performed was dependent on the patient's symptoms and image findings. The injections were performed by different orthopedic physicians after special training of injection techniques and under the supervision of a spine surgeon. The computed tomography-assisted periradicular injections were performed by a neuroradiologist Fig. . All facAfter inpatient injection therapy, the dose of analgesics was not increased, but was decreased whenever possible if less pain was present. Physical therapy was recommended depending on persistent symptoms, but not prescribed.Inclusion criteria were age > 18 years, subacute or chronic pain due to degenerative spine disorders, and no indication for urgent surgical therapy. Exclusion criteria were age < 18 years, pregnancy, and acute spinal diseases requiring specific treatment such as neurological deficits, inflammation, fractures, or tumors of the spine. In addition, patients with open wounds, intolerance to local anesthetics or corticosteroids and neurologic diseases were excluded, as well as patients with severe cardiovascular disease and coagulation disorders or taking anticoagulant medications.Written informed consent was obtained from all the patients. A positive vote from the Ethics Committee of the Medical Faculty of the University of Leipzig was available , and the study was conducted in accordance with the Declaration of Helsinki.The following injections were performed depending on the symptoms and radiological findings of the included patients: dorsal SIJ injection, perineural injections including transforaminal epidural injections, epidural interlaminar and epidural periradicular injections, and FJ injections. Possible complications were classified into general side effects and specific complications, and were recorded and evaluated for each individual injection , 13–15.The patient-specific parameters, such as age, sex, and weight, were analyzed. Patient complaints were classified as acute (less than six-week duration) or chronic (> 12 weeks). Clinical results were evaluated during inpatient admission, discharge, after six weeks, and after 12 weeks after admission.In addition, the data on the following parameters were obtained and evaluated during hospital admission, discharge, and at six and 12 weeks after discharge: the Numeric Analogue Scale (NAS) for pain, Oswestry Disability Index (ODI), and laboratory values for inflammation (C-reactive protein [CRP] and leukocytes [LC]) to monitor systemic infection.Graphs and analyses were generated using Microsoft Office 2019  and GraphPad Prism Software 9 . Data are presented as mean ± standard deviation (SD). The significance of the mean values was tested using unpaired t-test when the values were normally distributed and Mann–Whitney U-test when the values were not normally distributed. Fisher’s exact test was used when the sample size was small.Forty-eight consecutive patients were enrolled in this prospective study. The mean age of the patients was 58.38 ± 12.5 years (range 30–84 years). The female-to-male ratio was 1:1. The mean hospitalization stay was 6.25 ± 1.44 days (range 4–11 days). The overall mean number of injections for each patient was 5.88 ± 1.1 (range 4–9). In total, 282 spinal injections were performed and analyzed.The reasons for inpatient admission to spinal infiltration therapy varied. Thirty-four patients (70.83%) had chronic lumbar spine syndrome, five (10.41%) had lumbar disc herniation or spinal stenosis, four (8.33%) had chronic lumbar spine syndrome after previous surgery, three (6.25%) had chronic cervical spine complaints, and two had other underlying conditions (Scheuermann's disease and ankylosing spondylitis).Most patients suffered from back pain with a limited range of motion (93.8%), followed by sensory deficits (68.8%), ischiatic pain (50%), positive leg-raise test (35.7%), and chronic motor deficits 10%). Analysis of clinical symptoms over 12 weeks showed improvement in all parameters after injection therapy. Most improvements were observed between hospital admission and discharge. Sensory deficits were reduced by approximately 43.3%, ischiatic pain by 39.4%, limitation of motion due to pain by approximately 30%, positive leg-raise test by approximately 22.9%, and motor deficits by approximately 14.4%. After 12 weeks, the clinical symptoms recurred. Detailed values are presented in Table 0%. AnalyIn total, 282 spinal injections were administered. In descending order of frequency, 114 fluoroscopy-assisted infiltrations of the FJs , 50 injections of the SIJs, 49 periradicular injections , 37 epidural-interlaminar injections, and 32 epidural-perineural injections were administered. A detailed list of the medications used is shown in Table p < 0.001). At the 12-week follow-up, there was a rebound in NAS values, but the values were lower than those at admission (6.83 vs. 5.42). Analysis of the ODI values showed similar results. Between admission and discharge, there was a significant improvement in the ODI score . However, at 12 weeks of follow-up, the ODI increased to 44%. Analysis of inflammatory values (CRP and LC) showed no significant changes in the collected values at 12 weeks of follow-up  to discharge . Symptoms lasting > 10 h occurred in 43 (31.2%) patients, and on the day of discharge, symptoms due to injection were still present in four patients (2.9%). At the six- and 12-week follow-up, no treatment-related general side effects were observed.General side effects were observed for all injection types. In total, 131 common treatment-related events were recorded. The largest number of events had a symptom duration of < 10 h  at the injection site occurred in all infiltration types 32.4%–73.5%). Similarly, radiating pain (9.4%–34.7%) and sensory deficits (2%–18.4%) occurred in all groups. Both symptoms occurred mainly with injections into the nerve root region. Temporary headache was observed most frequently in the epidural-interlaminar group (13.5%) and least frequently in the FJ-injection group (1.8%). Mild circulatory dysregulation occurred in all groups (2.7%–4.1%), except in the FJ group. No severe systemic circulatory disturbances, systemic or local infections, or persistent neurologic disturbances were observed after the spinal injections. Intrathecal application with post-puncture syndrome occurred during epidural-interlaminar injection as a specific complication. Other specific complications, such as local and systemic infections, myelopathy, stellate blockade, pneumothorax, paraplegia, and renal puncture, did not occur. A detailed list of all observed side effects and specific complications is presented in Table %–73.5%. Analysis of the relative frequency of general side effects or specific complications per spinal injection type showed the highest rate of general side effects with periradicular injections (relative frequency [RF] = 0.8), followed by epidural interlaminar injections RF = 0.65). General side effects were rarest with FJ injections , Table . Generalp < 0.001), SIJ injection (p = 0.0031), and epidural periradicular injection (p = 0.0007)  Table .Table 6IThe aim of the study was to determine prospectively the general rate of side effects as well as specific complications in the context of inpatient injection therapy with different types of injections in the treatment of degenerative lumbar spine disorders.The results of this study show that the use of injections, based on the specific complaints in accordance with radiological findings, improved clinical symptoms, NAS, and ODI in the short term. This is consistent with the literature on conservative therapy for degenerative spinal disorders –19.Serious complications have been described in literature. These include infections, hematomas, intravascular injections, nerve injury, dura puncture, air embolisms, and their associated clinical signs .Side effects or minor complications occurred with all injection types in our study population. The range of relative frequency of general side effect was 0.32 to 0.8 overall. Various general side effects were observed with the periradicular injection technique. These included pain at the infiltration site, radiating pain, and temporary sensory deficits. These complaints are attributed to the application of the drugs directly to the corresponding nerve root or to local tissue trauma caused by needle placement or mild hematoma beside others.In a review of complications after transforaminal epidural injection, Change et al. reported a minor complication rate of 2.4%–9% . This fiOver the years, image-guided transforaminal injection using either CT, MRI, or X-ray has become standard. In a study between ct-assisted and anatomical landmark-guided injection, Demel et al. showed that ct-assisted periradicular injection resulted in a higher accuracy of needle position with better pain reduction. Major complications did not appear in both groups . Kamp etThe side effects of transforaminal epidural injection with steroids include vascular penetration, non-positional headache, back pain, worsening leg pain, facial flushing, hypertension, transient nerve root irritation, and vasovagal reactions . Our resDura puncture with subsequent injection into the subdural and subarachnoid spaces, resulting in complications such as cauda equina and conus medullaris syndromes, persistent paresthesia, infections, ascending weakness/loss of sensation, apnea, and unconsciousness, did not occur in our patients .SIJ and FJ injections are low-side-effect procedures. This is consistent with our data and shows up with the lowest RF of 0.32 compared to the other injections. Our patients mainly experienced short-term pain at the injection site and radiating pain. In a systematic review of FJ interventions, Boswell et al. showed only minor complications with the use of radiofrequency procedures in the FJs, but not in injections . Feared Epidural perineural and interlaminar injections had common side effects in our study. Local pain at the injection site was also the leading cause of pain. Headache was the most common symptom in both groups. In addition, disturbances in circulatory regulation have occurred. This is due to the effect of the steroids used and has been described in the literature .Temporary bladder dysfunction was also observed in few patients in the epidural interlaminar and periradicular injection groups. This can be explained by the fact that the administration of local anesthetics in the region of the lumbar and sacral nerve roots is associated with a higher incidence of urinary retention .In a systematic review, Vorobeychik et al. categorized the complications and side effects of non-image-guided lumbar interlaminar steroid injections into different categories. For this purpose, four groups were formed: technique, infection, steroid-use, and allergy. It is noted in the study that the described complications are only found in case reports in the literature. They concluded that only individually reported cases indicated high safety of the procedure . Dura puHeadache may also occur due to dural puncture. This could hypothetically be the reason for the high number of headache cases in the patient group . HoweverIntravascular application of anesthetics or steroids was not explicitly investigated in our patient group. Only few of the periradicular injections were performed with the application of contrast medium. The distribution of the contrast agent at injection was not explicitly studied.The individual cases that are described with serious complications due to the intravascular application of steroids, especially particulate corticosteroids, show that careful needle placement is also necessary. Although digital subtraction angiography is a standard technique for detecting intravascular application of transforaminal epidural injections, it cannot prevent serious neurological complications in individual cases .Hong et al. showed that the diameter of the needle used for infiltration has a significant influence on the incidence of intravascular application. Using digital subtraction angiography, a lower incidence of intravascular application was demonstrated with the Whitacre needle (5.4%) than with the Quincke needle (16%).However, this study did not differentiate between venous and arterial applications. A differentiation would be interesting from the authors' point of view since the intravascular application of insoluble steroids can cause paraplegia or ischemia in individual cases .The strengths of the study are its prospective study design, with a follow-up of up to three months after intervention. In addition, different types of consecutive injections were administered to patients within a specific duration. Another advantage is that we distinguished between general side effects and complications and recorded them explicitly after each infiltration. The disadvantages are the small number of patients and the small number of different types of infiltrations. We also did not evaluate the side effects or complications in terms of the drugs that were used. Further studies should be performed with a larger patient population, a detailed analysis of the applied drugs in terms of side effects, and a radiological evaluation of the distribution of contrast medium (if applied).Our study shows that even multiple consecutive infiltrations in the treatment of degenerative diseases of the spine has no accumulation of complications. Despite the frequent occurrence of side effects after injections, there is a significant reduction in pain and improvement in quality of life because of treatment in short-term follow-up. However, in the long-term study, the values obtained converge again.In summary, spinal injections for conservative treatment of degenerative diseases are safe and lead to a decrease in pain and improvement in quality of life. However, for each medical procedure, patients must be informed regarding the possible serious complications and the common occurrence of general side effects. Careful performance of injection techniques with accurate needle placement is essential for decrease in pain and complication rates.


To investigate the effect of 1% procaine injection, which is used in neural therapy, on shoulder pain and dysfunction in patients diagnosed with supraspinatus tendinopathy.The Range of Motion values, Visual Analog Scale and the QuickDASH Scale scores of 70 patients, who were diagnosed with musculus supraspinatus tendinitis based on magnetic resonance imaging findings, were analyzed. The data of the scales obtained before neural therapy and at the follow-up visit at four weeks after the end of therapy were compared, and a p-value of <0.05 was considered statistically significant.After neural therapy, a statistically significant increase was observed in Range of Motion values and there was a statistically significant decrease in both the Visual Analog Scale and QuickDASH score averages.This is one of the rare studies showing the effects of neural therapy application on shoulder pain severity and dysfunction in patients with supraspinatus tendinitis who are resistant to medical therapy. Shoulder impingement syndrome (SIS) is the most common cause of shoulder pain and dysfunction and typically results from the compression of the supraspinatus muscle tendon below the acromion.7NT is a simple and effective method of treatment by injecting local anesthetics into the most commonly symptomatic trigger points or alternatively into autonomic ganglia, scars, and other tissues.The study population consisted of patients who presented to the physical therapy and rehabilitation outpatient clinic of a tertiary treatment center with the complaint of shoulder pain in February 2020 and March 2021. After obtaining anamnesis and performing a physical examination, shoulder magnetic resonance imaging (s-MRI) was undertaken, and the patients with findings compatible with supraspinatus tendinitis were retrospectively examined. Seventy patients who were resistant to medical treatment , had neck pain for more than three months, and accepted neural therapy, were included in the sample.In this study, the range of motion (ROM) measurement technique was based on the guidelines of Kendall et al. In the supine position, shoulder flexion, abduction, internal rotation, external rotation, adduction; In the prone position, shoulder extension ROM measurements were made actively, each measurement was repeated three times and their average values were recordedPatients under the age of 18 years, pregnant women, patients with a history of who surgery in the shoulder girdle area, and those with inflammatory diseases or a history of cancer were excluded from the study.For all the patients, a total of three sessions of NT was performed at one-week intervals by a physical therapy specialist with a certificate of NT. In the first session, 1% procaine injection was administered to form a lentil-sized papule into the skin at painful points found by palpation around the shoulder. In addition, Quaddel was applied, and 0.5 cc 1% procaine was deep injected into segmental trigger points (into fibrositic nodules) detected by palpation. In the second session, the treatment protocol applied in the first session was repeated, and 1% procaine was injected to form a lentil-sized papule into the skin of the C5-T1 segments, which are the shoulder innervation segments. In the last session, the protocol used in the second session was repeated.16This study was approved by the local ethics committee of the training and research hospital .Data obtained and additional s-MRI results were analyzed using SPSS v. 21 software package. The normality of continuous variables was evaluated using the Shapiro-Wilk test. The paired t-test was used for the comparison of variables before and after treatment for normally distributed data, and the Wilcoxon test was conducted for those that did not conform to a normal distribution. Descriptive statistics were given as mean or median values with 95% confidence intervals. Statistical significance was accepted as p < 0.05. Spearman’s Rho correlation coefficient was used to determine the linear relationship between relative changes.The demographic distributions of the patients are shown in While an average decrease of 73.6% was observed in the VAS score after treatment compared to pre-treatment, this rate was observed as 59.95% for the Q-DASH score. After NT, the VAS scores evaluating shoulder pain and the Q-DASH scores indicating shoulder dysfunction were observed to have statistically significantly decreased compared to the baseline data (p < 0.001). IIIA moderate, positive, significant relationship was found between the rate of decrease in the VAS score and the Q-DASH score after treatment compared to the pre-treatment evaluation  .This is one of the most comprehensive studies showing the effects of NT application on shoulder pain severity, dysfunction and ROM in patients with supraspinatus tendinitis, who have chronic shoulder pain resistant to medical treatment and have not decided to undergo surgery.Complementary medicine approaches have found a place in the management of patients with treatment-resistant SIS. In a randomized controlled study investigating the effectiveness of acupuncture, after acupuncture treatment, functional improvements were achieved compared to the control group, and pain scores decreased.19Although there are studies in the literature reporting successful results with the use of NT in chronic musculoskeletal pain, research on its use in SIS is rare. In a patient who was followed up with a diagnosis of frozen shoulder, improvement was found in both pain scores and range of motion measurements of the patient with the application of NT.The main limitations of this study are the small number of patients and the lack of output regarding the long-term results of NT.NT involves much more than local injections, and it also includes other segmental and trigger point injections that should be evaluated from a holistic perspective. This study showed that NT might be an effective treatment method in patients with shoulder pain and functional limitation due to supraspinatus tendinitis.GYO: Conceived the idea, designed the study, and performed data collection and editing of manuscript.IB: Prepared the manuscript, performed statistical analysis and responsible for integrity of the study.