The treatment has also shown significant effectiveness in improving fatigue and sleep quality (p < 0.0001). Acupuncture has a beneficial effect on pain in all body areas in FM patients with high disease severity, with the greatest effects in the abdominal region and in the forearms, allowing a personalization of the treatment.To date, there is considerable evidence of the effectiveness of acupuncture in fibromyalgia syndrome (FM). However, it is not known in which body areas acupuncture is more effective. The objective of this study was to assess the improvements of pain induced by acupuncture in single body areas in patients with FM. In this open-label pragmatic study, FM patients in a state of high disease severity were consecutively enrolled and treated with a course of 8 weekly sessions of manual acupuncture. Patients were assessed with the Self-Administered Pain Scale (SAPS) of the Fibromyalgia Assessment Status at baseline and at the end of eight acupuncture sessions. Acupuncture sessions were all conducted with the same acupuncture formula  in each session and in each patient. Ninety-six FM patients completed the course of treatment. All the 16 body areas assessed by SAPS showed improvement in pain. A statistically significant improvement was achieved in 12 of the 16 body areas investigated, with the best results in abdomen and forearms ( Acupuncture, a therapeutic technique that goes back thousands of years, is still an effective treatment strategy for chronic musculoskeletal pain . In partAt present, randomized controlled trials (RCTS) have demonstrated the effect of acupuncture in the treatment of FM –7. The lHowever, in evaluating the effectiveness of acupuncture in FM, the majority of studies have focused mainly on generic patient-reported outcomes  , or diseThe clinical manifestations of FM are numerous: they are proteiform, it is often difficult to frame them, and the complexity of the clinical picture is also responsible for a significant diagnostic delay . HoweverRecently, the ACTTION-American Pain Society-Pain Taxonomy (AAPT) initiative proposed a revision of the ACR criteria, introducing the concept of multi-site pain (MSP), which defines FM if present in at least six of the nine possible body areas .Beyond the diagnostic definition and classification purposes of this complex sensory phenomenon that is CWP, there are no studies that have investigated in detail the improvements that acupuncture treatment can produce in different areas of the body. It is recognized that painful symptoms are more prevalent in some body regions in FM patients and occur more in the neck, upper back, and lower back .For proper clinical application, it is important to identify whether the beneficial effects of a general acupuncture formula on pain are greater in certain body regions than others.Starting from these considerations, the primary aim of this study is to assess the response to a general scheme of manual acupuncture, in terms of pain changes in single body areas in subjects with FM. The secondary aims of the study are to estimate the changes of fatigue and quality of sleep at the end of the treatment.This open-label, pragmatic, non-control study involved adult FM patients diagnosed according to 2010 ACR criteria . PatientPatients underwent a course of eight weekly acupuncture sessions according to a pre-established schedule. The outcomes studied were assessed one week after the end of the acupuncture treatment course compared to baseline, i.e., at the beginning of the treatment course.Acupuncture was not performed blindly and only one intervention group was chosen, in the absence of control groups. The reasons for this decision are explained later in Discussion.All patients voluntarily participated in the study and signed informed consent. The study was approved by the local ethics committee  and conducted in accordance with the 1964 Helsinki Declaration and subsequent amendments.For the purposes of this study, patients had to be in a status of severe FM, defined by the concomitant presence of a revised FIQ (FIQR) ≥39 and a Patient Health Questionnaire 15 items (PHQ15) ≥5 .All patients who had already undergone acupuncture even for indications outside FM, all patients with concomitant chronic painful conditions which could hamper patient evaluation or which could confound FM symptomatology , and all patients with relevant internistic diseases  or cancer (uncontrolled active neoplasms) were excluded.FM is frequently associated with other conditions such as lumbar or cervical spondylosis, peripheral osteoarthritis, or radiculopathies. These conditions were not considered as exclusion criteria as long as the dominant symptomatology was related to CWP.The procedures of this study were outlined according to the STandards for Reporting Interventions in Clinical Trials of Acupuncture (STRICTA) checklist .The manual acupuncture sessions were all conducted by a single physician (MDC), a rheumatologist with nine years' experience in acupuncture, with the certification to practice acupuncture in accordance with Italian law obtained in 2014 at the end of a four-year training period.The acupuncture scheme was performed according to the rules of Traditional Chinese Medicine (TCM). All patients were treated with the acupoints LV3, SP6, and ST36 on the lower limb, LI4 on the upper limb, CV6 and CV12 at abdominal level, Ex-HN-3 (Yintang), and GV20 at head level . Based oThe acupuncturist was allowed only minimal interaction with the patients at the beginning and end of the sessions, but was not allowed to make any questions about the state of health of the patients. The acupuncturist had no clinical and clinimetric information about the patients throughout the study.For the objectives of this study, the clinimetric evaluation was focused on Fibromyalgia Assessment Status (FAS)  23]. FA. FA23]. FAS contains three evaluations: two 11-point NRS scales related to fatigue and sleep quality and the Self-Administered Pain Scale (SAPS). This latter scale was the one used for the primary aim of this study. SAPS evaluates 16 body regions for the presence of pain on 4-point NRS for each area, where 0 represents no pain, 1 mild pain, 2 moderate pain, and 3 severe pain. The reference to painful symptoms is relative to the last week. SAPS is administered on paper with a front and back representation of a manikin, and for the 16 body areas the patient indicates the pain level in the scales from 0 to 3 for each area. The final SAPS score ranges from 0 to 48 and is transformed by a nomogram to a 0–10 scale to be computed within the FAS. In this study, the improvement of pain symptoms in the single body areas was evaluated on the SAPS.All questionnaires were administered by a fellow in rheumatology (GB), with experience in managing patient-reported outcome measures.For the purposes of this study, no formal sample size assessment was carried out. The case study enrolled is of convenience, determined by reasons of feasibility.The data of this study showed a nonparametric distribution (verified with the Kolmogorov–Smirnov test); therefore, the results are presented as median and interquartile range for FAS and subscales. The homogeneity of the case study was assessed with Levene's test for SAPS, FAS fatigue, and FAS sleep quality.In order to estimate the effect of acupuncture in each of the 16 body areas of the SAPS, and also to provide a graphical representation of acupuncture effects through a spidergram, mean SAPS values, not transformed by the nomogram, were calculated for each area at baseline and at the end of treatment.Changes between baseline and endpoint were evaluated using the Wilcoxon test for paired data.p < 0.05.The statistical analysis was conducted with MedCalc, version 18.0.0, and statistical significance was considered for values of The analysis was conducted on 96 of the 102 patients (94.1%) who started acupuncture treatment. In six patients, the course was suspended, at the second session in two patients due to poor tolerance to needle insertion, during the following sessions in the other four patients due to intervening logistics difficulties in carrying out the sessions on a weekly basis. Among the 96 patients treated, 85 (88.5%) were women and 11 (11.5%) men, with a mean age (±standard deviation) of 50.6 ± 12.3 years and a disease duration of 5.6 ± 6.2 years. The reference “optimal” drug therapy  was taken by 32 (33.3%) patients, 22 (22.9%) patients were taking only pregabalin, 13 (13.5%) patients were taking only duloxetine, and 29 (30.2%) patients were not taking either molecule.SAPS and FAS sleep disturbances data were homogeneous, whereas FAS fatigue data were not homogeneous.p < 0.0001)  . Analyzip=0.001). The four areas where the statistical significance of the improvement was not achieved were neck (p=0.058), chest (p=0.059), left buttock (p=0.065), and right thigh (p=0.052)  .p < 0.0001)  .To the best of our knowledge, this is the first study that investigated the effects of acupuncture, in terms of pain improvement, in the single areas of the body in patients with FM. This study showed that improvements induced by a general acupuncture formula are widespread, even in areas of the body not directly stimulated by needles. However, in some areas improvements are greater. It can therefore be affirmed that acupuncture has a global effect on CWP, the key symptom experienced by FM patients. Acupuncture demonstrated also to be effective to treat fatigue and sleep disturbances.Chronic musculoskeletal pain is the main reason why patients rely on acupuncture, followed by systemic symptoms such as fatigue , 26. TheThese integrated mechanisms ensure that, through a general formula in accordance with the TCM, such as the one applied in this study, generalized benefits can be achieved. For example, improvements can also be documented in areas of the body where no needles are inserted, such as the lumbar region. This finding has important clinical consequences because, while it is essential that the treatment is effective, it must be optimally tolerated and, specifically, the formula used in this study allows the patient to lie comfortably on his back during the sessions.However, it should be noted that the biggest improvements in terms of SAPS score difference between final and baseline were at abdominal level, where two acupoints (CV6 and CV12) were used. Our acupuncture formula included the treatment of 12 acupoints per session. Within the context of CWP of FM, where painful symptoms are also connoted by the presence of allodynia and hyperalgesia , it is essential to balance the use of needles since it is virtually impossible to treat every single painful body area. Probably the integration of a general therapeutic scheme such as or similar to that used in this study, with a microsystem-based technique , can provide even better results in terms of efficacy. However, this represents a theoretical speculation that should be the topic of future research.The use of SAPS as a clinimetric instrument has allowed a detailed analysis of the changes induced by acupuncture in each body area. There are several ways to measure CWP, such as the WPI in the ACR 2016 criteria or the AAPT criteria manikin . In thisNot least, our study confirmed the effectiveness of acupuncture on fatigue and sleep quality, the other two variables considered in FAS. It should also be emphasised that this cohort of patients belonged to a category with severe symptoms refractory to conventional pharmacological therapy.To date, there are no universally accepted treatment modalities for FM. What is widely accepted is the need for multimodal treatment approaches. Multimodal approaches, also suggested by international recommendations, are particularly useful for personalization of treatment, which is so important in FM, especially in patients with long-lasting symptoms , 30.This study confirms that acupuncture, integrated with pharmacological therapy, is beneficial for pain management in FM patients. Several studies have already demonstrated the effectiveness of acupuncture in FM. However, no previous study had demonstrated improvement in pain in individual body areas.Citing the limitations of the study, a first criticism that can be made is that no control group was used, in particular no group in which sham acupuncture was employed. We have chosen to treat all patients, first of all for the severity of their symptoms, since true acupuncture showed to be more effective than sham acupuncture in FM from recent meta-analyses , 31. SecA fourth limitation may be the fact that most of the patients were taking pharmacological treatment. The integration of acupuncture into multimodal schemes makes it more difficult to assess its therapeutic effect. However, all patients came from a failure/intolerance of drug therapy.This study showed how eight sessions of manual acupuncture treatment, using a general formula in accordance with TCM, has whole body beneficial effects on CWP in FM patients. Improvements can be documented in each body area, with the greatest effects in the abdominal region and in forearms. Acupuncture is confirmed as a complementary method that can be effectively integrated with other treatment strategies in FM.


Vulvodynia is a common chronic gynecological disease that affects approximately 16% of women, although it is rarely diagnosed. However, no known effective treatment exists. The etiology of vulvodynia is unknown and may be heterogeneous and multifactorial, so it is difficult—if not impossible—to improve this condition using 1 treatment method. Reports have shown that vulvodynia has an element of neuropathic pain. Although the role of the sympathetic nervous system in neuropathic pain is controversial, sympathetic nerve blocks have long been used to treat patients with chronic pain giving good results. A ganglion impar block (GIB), a sympathetic nerve block technique, may effectively manage pain and discomfort in patients with vulvodynia.Four patients suffering from chronic vulvar pain for 6 months–10 years were referred by gynecologists. The gynecologists could not identify the cause of the chronic vulvar pain, and symptoms were not improving by conservative therapy with medication. Patients complained of various chronic vulvar pain or discomfort. The initial visual analog scale (VAS) scores were 8 or 9 out of 10, and Leeds assessment of neuropathic symptoms and signs pain scale score was more than 12 out of 24. The review of gynecological medical records confirmed whether they showed allodynia during the cotton swab test and hyperalgesia to pin-prick test.All patients were diagnosed with vulvodynia.All patients were treated with a GIB, once in 2 patients, 3 times in 1 patient, and 4 times  in the other patient, under fluoroscopic guidance.After the procedures, the VAS score and the leeds assessment of neuropathic symptoms and signs (LANSS) pain scale score were decreased to less than 2 and 5, respectively, in all patients. Follow-up observations for 6 months–2 years revealed that 2 patients’ symptoms entirely or nearly entirely improved and did not require further treatment. The pain of the remaining patients were well controlled with medications only.GIB is a good treatment option for patients suffering from chronic pain and discomfort caused by vulvodynia. This was proven in subsequent studies.,4 Although the pain and discomfort caused by vulvodynia affect patients’ quality of life, their family, and intimate partner, it also becomes a significant burden on society and the healthcare system. Many women live with pain and sexual dysfunction without accurate diagnosis and proper management.–8 This may be due to the diversity of vulvodynia, making its cause challenging to be determined. Also, if the cause of vulvodynia is determined, it is often difficult to treat. Unfortunately, a particularly effective method for treating vulvodynia is unknown.In the United States, approximately 16% of respondents reported a history of chronic, burning, sharp knife-like pain, or pain on contact lasting at least 3 months. Nearly 7% was reported to be experiencing such problems at the time of the survey.,9 While the relationship between neuropathic pain and the sympathetic nervous system (SNS) is controversial, the relationship between the chronic pain and the SNS is well established.,11 Sympathetic nerve blocks have been used to treat chronic pain long time ago.–14 The ganglion impar  is the only unpaired ganglion of the SNS at the sacrococcygeal junction level. It conveys sympathetic efferent to and nociceptive afferent from the perineum, distal rectum, perianal region, the distal urethra and vulva/scrotum, and the distal third of the vagina and supplies sympathetic innervation of the pelvic viscera. There is a preliminary report that the ganglion impar block (GIB) effectively reduced the neuropathic component of chronic coccygodynia.Vulvodynia is widely accepted as neuropathic in origin.Authors reports successful pain and discomfort management in 4 patients with vulvodynia by the GIB under fluoroscopy guidance.2,17 The initial visual analogue scale (VAS) score was 8 out of 10, and the Leeds assessment of neuropathic symptoms and signs (LANSS) pain scale score was 13 out of 24. We diagnosed her with generalized vulvodynia. She had been prescribed various medications, such as 300 mg gabapentin, 2.5 mg tibolone, promestriene cream, 40 mg oxycodone, 120 mg fexofenadine, and 0.5 mg estriol. However, it did not control the symptoms, and it was impossible to increase oxycodone's dose because of nausea. Ultrasound-guided bilateral pudendal nerve blocks were performed with a mixture of 5 mL of 0.5% lidocaine and 10 mg triamcinolone at each side twice every 2 weeks. The VAS score dropped from 8 to 4 and 3 after 2 and 4 weeks, respectively. Though the VAS score was reduced by half, she complained of considerable discomfort in daily life. The fluoroscopy-guided GIB with a mixture of 5 mL of 0.5% lidocaine and 20 mg triamcinolone was performed. At the outpatient visit 2 weeks after the procedure, the VAS and the LANSS pain scale score dropped to 0, and the patient stopped complaining. No adjuvant treatment was performed, and the condition remained the same when she revisited after 6 months.Case 1 was a woman in her 60 second who complained of chronic pricking vulvar pain and an itching sensation lasting 2 years. She had hypertension and a history of 3 vaginal deliveries. Her chronic vulvar pain occurred suddenly without a specific cause, and the pain may extend to the inner upper thigh. She felt particularly uncomfortable sitting, making it challenging to sit for more than 10 minutes. The patient's gynecological medical records confirmed that she did not show allodynia during the cotton swab test but showed hyperalgesia to the pin-prick test.Case 2 was a woman in her 70 second who complained of chronic burning and stabbing vulvar pain and dysesthesia lasting 6 months. She reported that she started visiting a gynecologist 6 months ago because her symptoms were getting worse, but perhaps symptoms were minor, but they seemed to have existed before that time. She also reported having an gynecological operation a long time ago. She had hypertension, diabetes, depression, and Parkinsonism. She was once diagnosed and treated for somatoform disorder NOS. Her chronic vulvar pain occurred suddenly without a specific cause, and the pain may extend to the perineum. The gynecological medical records confirmed that she did not show allodynia during the cotton swab test but showed hyperalgesia to the pin-prick test. The initial VAS score was 8, and the LANSS pain scale score was 13. We diagnosed her with generalized vulvodynia. She had been prescribed various medications, such as 300 mg gabapentin, 2.5 mg tibolone, promestriene cream, 20 mg oxycodone, and 0.5 mg estriol, but it was unhelpful. A fluoroscopy-guided GIB with a mixture of 5 ml of 0.5% lidocaine and 10 mg triamcinolone to prevent excessive blood sugar rise was performed, and the VAS and LANSS pain scale score was reduced to 4 and 9 after 2 weeks, respectively. She did not feel much discomfort in daily life, even with a VAS score of 4. After, only drug treatment with 30 mg duloxetine, 150 mg pregabalin, and 0.5 mg estriol was performed. The VAS score and the LANSS pain scale score became 2 and 5, respectively, and were maintained continuously for 6 months. She remained with the same status for a year later without any treatment.Case 3 was a woman in her 70 second who complained of chronic burning and pricking vulvar pain on contact, itching sensation, and dysesthesia lasting more than 10 years. She had a history of cervical cancer surgery 10 years ago and was accompanied both lower extremity lymphedema. For 10 years, she had been treated in numerous hospitals, but there was no improvement. There was no problem before the surgery. She could not wear tight clothes since the onset of symptoms. On the day of her first referral, she was wearing men's square briefs. Her chronic vulvar pain occurred suddenly without a specific cause, and the pain may extend to the perineum. The gynecological medical records confirmed that she showed allodynia during the cotton swab test and showed hyperalgesia to the pin-prick test. The initial VAS score was 9, and the LANSS pain scale score was 19. We diagnosed her with generalized vulvodynia. She had been prescribed various medications, such as 150 mg pregabalin, 2.5 mg tibolone, promestriene cream, 20 mg oxycodone, 120 mg fexofenadine, and 0.5 mg estriol, but it was unhelpful. The fluoroscopy-guided GIB with a mixture of 5 mL of 0.5% lidocaine and 20 mg triamcinolone was performed twice every 2 weeks. Her VAS score after each procedure reduced from 9 to 5 and 4 after 2 and 4 weeks, respectively. After the procedures, the VAS score was reduced by half, and the patient was delighted with the procedure's results. However, it was challenging to come to the hospital because the patient lived far from our hospital. It was as hard as the pain and discomfort caused by vulvodynia for her elderly husband to come to our hospital by public transportation over 3 hours with his wife. She has limited mobility due to lymphedema of both lower extremities. The patient wished for her husband and herself to maintain her current condition without frequent visits to our hospital. Chemical neurolysis should only be performed in limited quantities in patients suffering from cancer pain. However, the authors could not ignore the patient's situation. After listening to a sufficient explanation about the risk of chemical neurolysis and taking enough time to think about it for 2 weeks, the couple voluntarily decided to conduct chemical neurolysis. The same procedure was performed once again with 3 mL of 2.0% lidocaine, and alcohol neurolysis with 2 mL of 99% alcohol was performed for the fourth time. The concentration of lidocaine was increased to check whether motor nerves were included, and the amount of lidocaine was decreased to check for the effect of alcohol neurolysis, which will be performed afterward. After the procedures, the VAS scores were reduced from 4 to 3 and 2 after 2 and 4 weeks, respectively. Fortunately, the procedure was finished without any side effects, and the patient was pleased with the procedure's results. The patient also received fluoroscopy-guided bilateral lumbar sympathetic ganglion blocks twice to relieve both lower extremity lymphedema. After the procedures, the patient underwent drug treatment with 30 mg duloxetine, 150 mg pregabalin, and 0.5 mg estriol and has maintained the VAS score and the LANSS pain scale score of 2 and 5, respectively, for 2 years.Case 4 was a woman in her late 30 second who complained of chronic burning, stabbing, throbbing, and electric shock-like vulvar pain on contact and dyspareunia 18 months ago. Symptoms have developed since receiving laparoscopic low anterior resection surgery and postoperative adjuvant radiation therapy 18 months ago. There was no problem before the surgery. After the surgery and postoperative adjuvant radiation therapy, she could not have a normal sex life with her husband due to severe dyspareunia during insertion. Also, she could not wear tight pants such as jeans. Her pain was confined to the vulvar vestibule area. The gynecological medical records confirmed that she showed allodynia during the cotton swab test and showed hyperalgesia to the pin-prick test. The initial VAS score was 9, and LANSS pain scale score was 19. We diagnosed her with localized, provoked vulvodynia (provoked vestibulodynia). She had been prescribed various medications, such as 60-mg duloxetine, 300-mg pregabalin, 16-mg hydromorphone, and 0.5-mg estriol from gynecologists, but it did not help to control the symptoms. The patient underwent fluoroscopy-guided GIB with a mixture of 5 ml of 0.5% lidocaine and 20 mg triamcinolone 3 times every 2 weeks. After the procedures, the VAS scores were reduced from 9 to 5, 4, and 2 after 2, 4, and 6 weeks, respectively. The VAS score and the LANSS pain scale score became 2 and 5, respectively, and were maintained continuously for 2 years. She underwent only drug treatment with 30 mg duloxetine, 150 mg pregabalin, and 0.5 mg estriol and had a normal sex life again.Ganglion Impar Block: All procedures were performed with informed consent under the Helsinki Declaration before implementation. All fluoroscopy-guided GIBs were performed using a trans-sacrococcygeal ligament approach technique. After placing the patient in a prone position on the C-arm table, the sacrococcygeal ligament area was identified under fluoroscopic guidance. The area was aseptically sterilized and draped sufficiently. The skin entry point of the 22G spinal needle was at the midline of the sacrococcygeal junction identified under fluoroscopic guidance. Infiltration was performed with a small amount of 2% lidocaine at the identified skin entry point. A spinal needle was inserted into the midline of the sacrococcygeal junction under fluoroscopic guidance. After penetrating the skin and dorsal sacrococcygeal ligament, passing through the sacrococcygeal disc, the needle tip was placed anterior to the ventral sacrococcygeal ligament using the loss of resistance technique. A radiocontrast (0.5 mL) was injected, and the correct position of the needle was confirmed using the “reverse comma sign”  and normal vaginal walls and secretions, in association with introital sensitivity to the cotton swab test, and pelvic floor muscle tenderness seen in some patients, can diagnose vulvodynia. Women more than 70 years have a lower prevalence of vulvodynia than younger women, but sexually active women ≥70 years have a similar prevalence to younger women. Among the 4 patients included in this case series, 3 were elderly (in their 60 second and 70 second), and only 1 patient was in her late 30 second. The number of patients is small; therefore, accurate judgment cannot be made. However, perhaps this is because younger patients are more reluctant to accurately reveal the actual situation, even to gynecologists, even if they suffer from vulvodynia. Among the types of vulvodynia, provoked vestibulodynia is the most common type. However, it is seen that the generalized vulvodynia was more common in this case series because 3 of the 4 patients were elderly (in their 60 second or 70 second). Generalized unprovoked vulvodynia is less common and typically present in older women.Although the incidence of vulvodynia is highest in younger women, vulvodynia can occur in women of all ages, including postmenopausal women. Mechanical hyperalgesia/allodynia and thermal hyperalgesia are common sensory signs in patients with different etiologies of neuropathic pain and surrogate animal and human models with neuropathic pain. Neuropathic mechanisms likely contributed to the patient's pain when the LANSS pain scale score is 12 or higher. Considering that the patients in this case series had a LANSS pain scale score of 12 or higher, it is thought that all patients’ pain in this case series should be treated as neuropathic pain. Neuropathic pain is caused by a lesion or disease of the somatosensory nervous system. According to this definition, vulvodynia cannot be designated as neuropathic pain. If vulvodynia is excluded from neuropathic pain, there is a risk that patients will be stigmatized for having a somatization disorder, which is neither a real nor obvious abnormality. However, they are suffering from a physical condition. Since this pain does not fit into the concept of neuropathic pain, it led to the use of other undefined descriptors of vulvodynia, such as dysfunctional or psychosomatic pain, which does not provide insight into possible mechanisms. It may also stigmatize patients causing only psychological suffering.Vulvodynia is characterized by mechanical allodynia and hyperalgesia localized in the vulvovaginal area.,11 Sympathetic nerve blocks have long been used to treat various chronic or neuropathic pain.–14 Although the innervation of the ganglion impar is not accurately known, GIB was first described in 1990 by Plancarte et al to treat sympathetic pain of malignant origin, and it has been used to treat various diseases.,26 Four techniques can be followed when performing GIB; they include the anococcygeal ligament, trans-sacrococcygeal approach, intercoccygeal joint approach, and paracoccygeal approach. All fluoroscopy-guided GIBs were performed using the trans-sacrococcygeal ligament approach technique. Regardless of which technique was used, knowing the exact location of the ganglion impar is essential to perform the procedure accurately. Oh et al reported that although the anatomical position of the ganglion impar is variable, it is located within 0.6 from the midpoint of sacrococcygeal joint, assuming that the distance from the midpoint of sacrococcygeal joint to the tip of the coccyx is 1. To confirm whether the drug to be injected will reach the ganglion impar, we injected the radiocontrast several times to check whether the radiocontrast reached enough from the sacrococcygeal joint to 0.6 before injecting the drug. In addition to GIB, a case report showed promising results by treating vulvodynia with lumbar sympathetic ganglion block, another kind of sympathetic block.The relationship between neuropathic pain and SNS has not been fully elucidated. However, the relationship between chronic pain, such as vulvodynia and the SNS, is well established. Therefore, a multidisciplinary approach is vital for treating patients with vulvodynia. The principle of treating patients with vulvodynia is that a multidisciplinary approach, including psychotherapy, pelvic physical therapy, and medical therapy, must be taken, and treatment tailored to individual characteristics must be performed.All patients took medications only before the first visit. Each gynecologist prescribed slightly different medications, but they were unhelpful to the patients. In addition to the difficulty in treating vulvodynia, what is more problematic in this situation is the lack of communication between specialized subjects due to the specialization and subdivision of medicine. Most of the patients with vulvodynia see a gynecologist first. However, most gynecologists do not know much about other possible interventional treatment methods other than the known conservative treatment methods, even if they have an accurate diagnosis. Even if there are reports that GIB is effective, it is highly likely that many gynecologists are not aware of it. Vulvodynia remains a diagnosis of exclusion. Taking this into account, gynecologists play a significant role in excluding other causes of vulvar pain, screening for psychosexual and pelvic floor dysfunction, and co-working with other healthcare providers to manage pain in women. known to be the best for confirming the degree of pain and effect before and after the procedure, respectively, was sufficiently explained. However, unfortunately, 3 patients in their 60 second or 70 second refused to take the tampon test because they did not have dyspareunia because they were not sexually active. The other younger patient in her late 30 second refused the tampon test for fear of experiencing the same severe pain. Despite these limitations of this case series, the authors believe that the results of this study will help physicians to consider GIB as one of several treatment options.There are some limitations to the results of this case series. First, the number of patients included in this case series is only 4, so it is difficult to generalize the results. Second, since this study used a retrospective chart review, a thorough physical examination using the cotton swab test or tampon test was not performed every time a patient visited for follow-up. At every follow-up at the pain clinic, like other general patients visiting the pain clinic, the procedure results were confirmed using the VAS and LANSS score, which the patient directly expressed. However, in the case of pain physicians, it is also essential to consider that in most cases, the VAS score directly expressed by the patient is a commonly used method when determining the procedure's effectiveness. The tampon test's significance,In conclusion, GIB can be an effective interventional treatment method for treating vulvodynia, and a multidisciplinary approach and multimodal treatment are essential to treat vulvodynia effectively.Conceptualization: Dae Gy Hong, Jun-Mo Park.Data curation: Seong-Min Hwang.Formal analysis: Dae Gy Hong, Jun-Mo Park.Investigation: Seong-Min Hwang, Jun-Mo Park.Methodology: Jun-Mo Park.Project administration: Dae Gy Hong, Jun-Mo Park.Supervision: Dae Gy Hong, Jun-Mo Park.Validation: Dae Gy Hong.Writing – original draft: Jun-Mo Park.Writing – review & editing: Dae Gy Hong, Seong-Min Hwang, Jun-Mo Park.


Propofol is the most frequently used anaesthetic agent. Despite various anaesthetic benefits, propofol is not without side effects, pain on injection being the most common adverse effect. This study aimed to find the grade of pain reduced due to the injection of propofol after administration of lidocaine.A descriptive cross-sectional study was conducted from March 2015 to August 2015 in the operating theatre in a tertiary care hospital after taking ethical clearance with an ethical clearance from the Institutional Review Committee. A total of 64 participants fulfilling all inclusion criteria of both gender, age ranged from 16-65 years of American Society of Anesthesiologists physical status I and II ready for elective surgery under general anaesthesia with propofol pretreated with 60mg lidocaine with venous occlusion for one minute were observed. The pain was graded by the four-point scale . Haemodynamic variables were measured until just before intubation.In patients pretreated with lidocaine, no pain 56 (87.5%), mild pain 8 (12.5%) and moderate pain 0 (0%) were observed.The grade of pain during injection of propofol was reduced in more than three-fourth of the patients after administration of pre-anaesthetic drug-like lidocaine. Propofol is the most frequently used anaesthetic today. Despite its various anaesthetic advantages, propofol is not without side effects; among which, pain on injection is the most commonly reported adverse effect.3Several methods have been used to reduce this pain. Of all, lidocaine pretreatment with venous occlusion or injection in the large vein is most effective.Thus, the study aims to find the grade of pain reduced due to the injection of propofol after administration of lidocaine.A descriptive cross-sectional study was conducted in the operating theatre at the National Academy of Medical Sciences (NAMS), Bir Hospital. Data collection was carried out for a six-month duration (from March 2015 to August 2015). Before commencing this study, ethical clearance with an ethical approval number of 134/14 was obtained from the Institutional Review Committee (IRC), NAMS, Bir Hospital.Inclusion criteria were those who gave consent, patients belonging to the American Society of Anaesthesiologists (ASA) physical status I and II, and requiring elective surgery under general anaesthesia, the participants of both gender aged 16 to 65 years. Exclusion criteria were those unwilling to voluntarily participate in the study. Patients were also excluded if they had any known allergy to study drugs, had difficulty communicating, and if on concomitant use of pain modifying drugs like analgesic or sedative drugs within the 24 hours before surgery or had peripheral vascular diseases.Convenience sampling method was used. Sample size was calculated using the formula:where,n = minimum sample sizeZ = 1.96 at 95 % Confidence Intervalp = 50%, prevalence for maximum sample sizeq = 1-pe = margin of error, 13%Taking 10% non-response rate of study participants. The sample size calculated was 63. However, the total sample taken was 64.A total of 64 participants ready for elective surgery under general anaesthesia pretreated with 60mg lidocaine (volume of 5ml) with venous occlusion for one minute were observed. The pain was assessed by a four-point scale . Haemodynamic variables were measured until just before intubation.Written informed consent was taken from each participant of the study. A semi-structured questionnaire and an observational checklist were used for data collection and face to face interviews were taken. For the data collection, the pre-structured questionnaire was made by reviewing different literature and seeking opinions from the experts on the subject; thereafter appropriate modification was done. All patients fulfilling the inclusion criteria were noted in the questionnaire from the relevant patient file record. Data was collected before operation by face-to-face interview at the bedside along with a record file. Participation was voluntary and utmost confidentiality and personal identity of all the participants were assured.After fully explaining all the procedures to the patients, venous occlusion was done by applying a venous tourniquet over mid-arm. The patients were injected intravenously 60mg preservative-free lidocaine diluted in 2ml of isotonic saline. Five ml disposable syringe was used. After 1 minute, the tourniquet was released followed by an injection of 25% of the total induction dose of propofol (2mg/kg) at a rate of 0.5ml/sec by an anaesthetic assistant. Patients were then assessed about pain according to four-point verbal categorical systems and behavioural signs as given below:Hemodynamic parameters-heart rate and blood pressure were recorded two minutes before tourniquet as a baseline, after a test dose of propofol, after induction, before intubation. The collected data was entered in Microsoft Excel and converted into SPSS  software package 20 version for statistical analysis. Data were analyzed using descriptive statistics. Continuous data were expressed as mean and standard deviation and categorical variables as number and percentage.A total of 64 participants were enrolled in the study. There was no experience of severe and moderate pain by participants pretreated with lidocaine whereas mild pain was experienced by 8 (12.5%) participants. A higher no of participants that is 56 (87.5%) had no experience of any pain. The grade of pain on injection of propofol among lidocaine by verbal rating score after giving 25% of the calculated dose of propofol is shown .The baseline mean heart rates of 89.5±12.65 bpm in patients pretreated with lidocaine .The baseline mean arterial blood pressure among patients who are given lidocaine is 97.5±11.43 mm Hg. .The minimum and maximum age of the patients were 16 and 60 years in patients pretreated with lidocaine. Likewise, the mean age of the patients were 37.69±13.34 years to whom lidocaine was given .The mean weight of the patients was 56.11±8.82 kg in patients who were given lidocaine. Similarly, out of the total number of 64 patients pretreated lidocaine, 53 (83.3%) were of ASA I and 11 (16.7%) were of ASA II.5The single discovery of general anaesthetic agents into clinical practice facilitated the development of modern surgery and helped in the expansion of the speciality of anaesthesiology. These techniques evolved first with inhalation anaesthesia, followed by local and regional anaesthesia and finally intravenous anaesthesia. Induction during general anaesthesia could be achieved by using intravenous or inhalation agents. Modern-day intravenous anaesthetics have replaced inhalation agents but none of the agents available at present meets all these requirements.6 The pain probably results from either direct irritant effects or indirect effects through activation of the plasma kinin cascade. The peripheral veins are innervated with polymodal nociceptors that mediate responses to the injection that causes pain. Other possible explanation for pain includes osmolality differences and unphysiological pH.1Propofol is a commonly used intravenous anaesthetic and is often the induction agent of choice. However, pain on injection is a major drawback due to its highly osmotic lipid solvent and propofol's irritant effect on the vascular intima.7 Some of them include varying the speed of injection, cooling or diluting the propofol solution, injecting propofol into large antecubital veins, pretreatments or simultaneous injection of different drugs. Drugs commonly used are Lidocaine, Tramadol, Ketamine, Sodium Thiopental, Nitroglycerin, Ketorolac, Paracetamol, NSAIDS, Metoclopramide, Ondansetron, Granisetron, Fentanyl, Remifentanil, Pethidine and Alfentanil.9Several physical and pharmacological strategies have been used to reduce this pain but the best means has yet to be determined.10 The efficacy profile of lidocaine as a local anaesthetic is characterized by a rapid onset of action and intermediate duration of efficacy. Reduction of pain induced by propofol injection by lidocaine may be due to local anaesthetic effect and stabilizing the kinin cascade.11 The observation that pain was reduced or absent when the drug was injected into an antecubital vein led to the speculation that increasing the diameter of the vein by vasodilation might reduce the incidence of pain when propofol is injected into the dorsum of the hand.12Of various methods, lidocaine pretreatment with venous occlusion or injection in the large vein is most effective. Lidocaine is a commonly used amide local anaesthetic.14This study was conducted to observe the prevalence of pain during the injection of propofol after the administration of pre-anaesthetic drug such as lidocaine. Various grading of pain was observed during propofol injection in our study. In patients pretreated with lidocaine, no pain 56 (87.5.%), mild pain 8 (12.5%) and moderate pain 0 (0%) were observed. The findings of our study also showed lidocaine were effective in the reduction of propofol-induced pain in accordance to the findings of other studies.15A systematic review by Jalota, et al. concluded the two most efficacious interventions to reduce pain on injection of propofol were use of the antecubital vein, or pretreatment using lidocaine in conjunction with venous occlusion when the hand vein was chosen.From the findings of this study, it can be concluded that the grade of pain during the injection of propofol was reduced in more than three-fourth of the patients after the administration of pre-anaesthetic drug-like lidocaine. Thus, lidocaine can be safely administered in clinical practices.


By distracting patients, virtual reality (VR) may have a role in painful procedures. We compared VR vs. an inhaled equimolar mixture of Nmin − ANI0) during the procedure, based on ANIm (average on 4 min). We prespecified VR as non-inferior to Kalinox® with a margin of 3 points. Self-reported pain and anxiety were also analysed using numeric rate scale (NRS).Prospective, non-inferiority, open-label study. Patients were randomized, for Kalinox® or VR session during drain removal. The analgesia/nociception index (ANI) was monitored during the procedure for objective assessment of pain and anxiety. The primary endpoint was the ΔANI . The mean difference was, therefore, − 0.6 [− 3.6 to 2.4], including the non-inferiority margin of 3. Patients in the VR group had a significantly higher pain NRS scale immediately after the drain removal, 5.0 [3.0–7.0] vs. 3.0 [2.0–6.0], Based on the ANI, the current study showed that VR did not reach the statistical requirements for a proven non-inferiority vs. Kalinox® in managing pain and anxiety during chest drain removal. Moreover, VR was less effective based on NRS. More studies are needed to determine if VR might have a place in the overall approach to pain and anxiety in intensive care units.Trial registration NCT, NCT03956264. Registered 20 May 2019, https://clinicaltrials.gov/ct2/show/NCT03956264 The management of acute pain and anxiety related to healthcare interventions remains a major challenge, especially in the intensive care unit (ICU). Pain is common in critically ill adults at rest and during procedures including regular activities  and discrete procedures . Chest tube removal, wound drain removal, and arterial line insertion were described to be the three most painful procedures, with median pain scores of 5 (3–7), 4.5 (2–7), and 4 (2–6) on a 0–10 numeric rating scale, respectively . Patients had a choice between five different immersive environments (360° videos): a snowy mountain, a landscape in India or in Camargue (France), a balloon ride or a canoe descent.Establishment of a communication code before starting the VR was performed to warned patients before removing the tube . The VR session started during the preparative phase, at least 5 min before the removal of the drains, and was continued for 10 min after. We used a VRx helmet 90-degree field of view with head tracking,  when not. Categorical variables were expressed as a number (percentage). Categorical variables in two groups were compared using the Chi-squared and Pearson’s tests. Comparison of normally distributed variables used the Student-n = 99) or to the Kalinox® group (n = 101), 96 patients received the treatment and 90 were analysed in per protocol analysis . In the VR group, 95 patients received the VR session and 90 were analysed . A flow diagram is presented in Fig. From September 2019 to July 2020, 246 adult patients were screened. Of those, 15 refused to participate in the study and 31 did not meet the inclusion criteria. Finally, 200 patients gave written informed consent and were randomized to the VR group . Patients’ satisfaction was higher in the Kalinox® group (p = 0.002). In detail, 89 (99%) patients were satisfied and very satisfied with Kalinox® vs. 81 (90%) with VR, p = 0.009. The nurses’ satisfaction (satisfied and very satisfied) was 97.2% in the whole cohort and did not differ between the two groups (p = 0.69). Three minor side effects were declared in the VR group (2 vertigo and 1 nausea) and also three in the Kalinox® group (2 euphoria and 1 headache).In the primary analysis, the ΔANI was − 15.7 ± 11.6 in the VR group and − 15.1 ± 12.9 in the Kalinox® group; the mean difference was, therefore, − 0.6, with a 95% confidence interval of − 3.6 to 2.4. The lower limit of the 95% CI for the reported difference was, therefore, lower than the non-inferiority margin (3.6 vs. 3). The ANI data and trial outcomes are presented in Table Although easy to use, well tolerated and providing satisfaction in 90% of patients and 97% of nurses, our study failed to prove the non-inferiority of VR compared to Kalinox® when removing drains after cardiac surgery. Based on the ANI, the results were not statistically different; however, they did not reach the statistical requirements for a proven non-inferiority. Based on the NRS and on patient satisfaction, the results were significantly in favour of Kalinox®: the feeling of pain immediately after the procedure in the VR group was significantly higher than in the Kalinox® group. This is at odds with the results of a recent meta-analysis, where VR was able to reduce pain in various painful situations, such as burn wound care. However, these results were based on small studies that were clinically and statistically heterogeneous, using only a pain score . Some prPain management in the ICU is still a challenge, especially in cases of brief painful care, such as during drain removal. Opioid drug use is not the best treatment option in this situation due to their onset and duration of action and their digestive and neurological side effects. Besides, morphine use was extremely low in this study. Kalinox® seems to be a good compromise, because it is easy to use, has a short onset of action and a short duration after removal. Moreover, it has shown a reduction of acute pain and anxiety with low side effects.Anxiety is also an important issue in the ICU and could result in persistent symptoms after discharge and/or depression . In addiAlthough limited interest to reduce pain, VR seems to be a promising adjunctive therapy in ICU, as it is well-tolerated, non-invasive, and could reduce stress and anxiety. The improvement of VR devices with higher 360 video quality, more immersive environments with the possibility of adding hypnosis techniques, as well as the greater availability of this type of accessory in ICU, makes it an interesting tool to experiment in near future.This study presented some limitations. First, it was a single-centre study, corresponding to a specific experience. We performed this study on a specific situation  in cardiac surgery patients, which can make it difficult to generalize. Patients were not included if they were judged unable to understand by investigators, but we did not use delirium evaluation with specific scale. Second, we used a specific VRx device, and each VR device may not be suitable for all patients. With this device, patients could choose their immersive environment and navigate into it. Some patients may need more interactivity, self-customization and social interaction for a full VR experience, and this could have reduced the effectiveness of the VR session. Furthermore, we fixed a range of non-inferiority of 3 and anticipated a change of ΔANI of 25 ± 8. This threshold could have been too restrictive. Finally, we could not exclude a lack of power to demonstrate the non-inferiority of VR and Kalinox®.Although VR was well tolerated by patients and allowed a satisfying self-reported anxiety control during drain removal after cardiac surgery, it failed to prove non-inferiority compared to Kalinox® for the management of pain and anxiety, as assessed by ANI, and was less effective based on NRS. More studies are needed to determine if VR might have a place in the overall approach to pain and anxiety in intensive care units.


To compare gender differences in pain management among adult cancer patients in Saudi Arabia and to explore the predictors associated with attitudinal barriers of cancer patients to pain management.A descriptive cross-sectional study was conducted among 325 cancer patients from tertiary hospitals in Saudi Arabia.N = 219) and 32.6% were men (N = 106). The overall mean scores of the attitudinal barriers questionnaire were 49.51 ± 13.73 in men and 54.80 ± 22.53 in women. The analysis shows significant differences in scores in subscales of tolerance (men = 7.48 ± 2.37), (women = 8.41 ± 3.01) (p = 0.003) and fear of distraction in the course of treatment (men = 6.55 ± 1.34), and (women = 7.15 ± 2.63) (p = 0.008). Female patients reported a more moderate to severe level of pain than men . Splitting by gender, the significant predictor for physiology effect domains in male cancer patients includes age, marital status, employment status, monthly income, cancer type, and presence of comorbid disease (p < 0.050). Age was a significant predictor of the domains of fatalism, communication, and harmful effects (p < 0.050) among female cancer patients.Of the total participants, 67.4% were women (The present study revealed significant differences between men and women with attitudinal barriers to cancer pain management. Managing pain requires the involvement of all methods in a comprehensive manner, thus unalleviated pain influences the patient’s psychological or cognitive aspect. Pain is a common and burdensome symptom among cancer patients . ApproxiCurrently, several pain treatment guidelines exist among patients and clinicians that have been directing the course of treatment . AccordiPatient-related barriers to pain management are defined as misguided assessments and misunderstandings that include the feeling of fear of dependence, tolerance, and side effects, reluctance to let physicians try to cure the disease, and belief that cancer pain is an inevitable component in the course of disease . In addiPrior research involving pain and cancer patients explored the association between patient adherence and gender . The resThe sample population of this descriptive cross-sectional study included 325 patients with a confirmed diagnosis of cancer. Inclusion criteria for the patients were (a) age 18 and older, (b) Saudi nationals, (c) patients with a confirmed diagnosis of cancer, (d) ambulatory and capable patients able to work at least light work, and without restriction, and (e) patients who experienced pain of at least 1 on a range of 0–10 in the past 2 weeks. Ethical approval was obtained from the research ethics committee at King Saud University.Data gathering started in January 2019 and was completed in April 2019. Data were collected from three public tertiary hospitals in Saudi Arabia. The selected hospitals were chosen because they are referral hospitals with surgical and oncology specialties established by the Ministry of Health. We distributed 125 questionnaires in each hospital and all eligible participants were recruited using convenience sampling during their visit in the hospital. After attending the medical consultation, all participants were asked to fill in an English-Arabic-translated questionnaire. A trained researcher explained the purpose of the study and their rights in answering the questionnaire. Before the distribution of the questionnaire, approval from the medical directors of the clinics was sought and all attending doctors were asked to set a time to interact, and facilitate the data collection. Written consent was obtained from the respondents before distributing the questionnaire. In addition, all participants were informed before filling out the questionnaire that they could choose to remain anonymous and decline to participate at any time as well as have the option of not completing the questionnaire.The questionnaire was designed to measure attitudinal barriers to cancer pain management. The first part of the questionnaire included demographic characteristics and clinical history of the participants. The second part of the questionnaire was the 27-item Barriers Questionnaire II (BQII) which has eight beliefs and four categories:The eight beliefs are:•Fear of addiction•Concerns about tolerance•Fatalistic beliefs•Fear from the side effects of medication•Desire to be a “good patient”•Fear about interfering and distracting in a physician’s course of treatment•Concerns about ability to monitor changes in one’s body•Fear medication may affect the immune systemThe four dimensions include:•Physiologic effect (12 items)•Fatalism (3 items)•Communication (6 items)•Harmful effects (6 items).The items were measured on a 6-point Likert scale  which is a multidimensional pain evaluation tool measuring the presence of pain, intensity, and effect in hindering general activities. The items include questions about feeling of least pain, worst pain, average pain, and pain now during the last 24 h and scored through a visual analog scale (0 no pain to 10 extreme pain) . The last-tests were employed to examine differences in eight beliefs and domains of attitudinal barriers as well as pain intensity. Then, t value, degrees of freedom, and effect size were calculated for each subscale and domains. Additionally, multivariate analysis of variance (MANOVA) was used to assess the differences in attitudinal barriers to cancer pain management for men and women. Linear regression analysis was used with gender as a moderator to determine predictive factors of attitudinal barriers to pain management of cancer patients. A p = value was also considered statistically significant when P < 0.05.All data were entered and analyzed using the statistical software package SPSS version 23.0 . Descriptive statistics were used to describe the frequencies of the participants. Independent N = 219) and 32.6% were men (N = 106). The analysis shows a significant difference between gender and demographic characteristics such as age, marital status, educational level, and employment status. The number of employed female patients was significantly higher than that of male patients (P < 0.01). As can be seen, breast cancer was the most common cancer disease among women  and colorectal cancer was the most common among men . In the male group, 37.2% had diabetes mellitus, followed by 8.5% of other types of comorbid disease, and 7.5% had hypertension. Twenty-three percent of women had diabetes mellitus, 8.3% had hypertension, and 5.6% had other types of comorbid disease (P < 0.01). The mean Karnofsky Performance Status (KPS) score for men was significantly higher than women .Out of 375 questionnaires distributed, 325 participants (86.6%) took part in the study. p = 0.003) and fear of distracting in the course of treatment (men = 6.55 ± 1.34), (women = 7.15 ± 2.63), and (p = 0.008). The magnitude of the difference of tolerance and fear of distracting in the course of treatment was very large with eta squared = 0.343 and 0.287, respectively. In the domains of attitudinal barriers, it shows that the scores of women (11.52 ± 6.84) in harmful effects was greater than the scores of men (9.25 ± 3.91) (P = 0.001) with a very large magnitude of difference (eta squared = 0.407).The attitudinal barriers to pain management of cancer patients by gender are presented in p = 0.001). Female patients had a mean score in “worst pain in the last week” of 7.07 ± 1.50, “least pain in last week” of 6.15 ± 1.63, “average pain” had a mean score of 6.35 ± 1.71, and “pain right now” was 6.11 ± 1.63. Meanwhile, male patients had a mean score in “worst pain in the last week” of 5.84 ± 2.65, “least pain in last week” of 4.83 ± 2.55, “average pain” had a mean score of 4.76 ± 5.56, and “pain right now” was 4.62 ± 2.40. Pain interference can be classified as no interference to interferes completely. There was a significant difference between men and women for pain-related functional interference (p = 0.001). Male participants reported least more likely functional interference compared to women. For example, in terms of general activity, men had a mean score of 4.60 ± 2.43 while women had a mean score of 6.90 ± 1.60. Other factors had similar trends: Mood , walking ability , normal work , relationship with other people , sleep , and enjoyment of life .F = 17.46, p = 0.001; Wilks’ Lambda = 0.59; partial eta squared = 0.40. When the results for the dependent variables were considered separately, the only difference to reach statistical significance using a Bonferroni adjusted alpha level of 0.027, were tolerance, F = 11.42, p = 0.001; partial eta squared = 0.34; immune system, F = 9.20, p = 0.003; partial eta squared = 0.28; pain intensity index, F = 48.97, p = 0.001; partial eta squared = 0.13; and harmful effects, F = 10.02, p = 0.002; partial eta squared = 0.30.A MANOVA was performed to investigate the gender difference in attitudinal barriers to pain management of cancer patients . Eight bp < 0.050). Age was a significant predictor of the domains of fatalism, communication, and harmful effects (p < 0.050) among female cancer patients. Female and older cancer patients complained of more fatalistic beliefs about cancer-associated pain, and had concerns in reporting to physicians about treating the underlying disease. Furthermore, older, female, and breast cancer patients, and patients with a comorbid disease had more concerns, and fear of drug addiction and the harmful effects of pain medicine to the immune system. Meanwhile, younger male cancer patients had more concerns about physiologic effects than older cancer patients (p = 0.009). For both male and female participants, marital status and employment status were significantly associated with all of the subscales of attitudinal barriers (p = 0.001). Educational attainment was linearly correlated in the domains of communication among male participants while fatalism was correlated among female participants (p = 0.001). The analysis also revealed that the patients’ type of cancer was a significant predictor in all domains of attitudinal barriers (p < 0.50). The presence of comorbid disease was found to be significantly correlated with the physiology effect domains and communication domains as well as the harmful effect domain in male cancer patients (p < 0.50). In female cancer patients, the presence of comorbid disease was significantly a predictor in the domains of physiologic effect and communication (p < 0.50).Cancer pain is a complex condition with an association of severe and prolonged pain that causes a spiritual crisis, and behavioral, emotional, and physical changes that initiate conflicting effects on patients’ aspect of life . The incThe results of this study suggest that men and women demonstrate dissimilar degrees of pain management. Female patients were more concerned about the physical effects of cancer and side effects of analgesics than men. Our findings are in line with previous studies in which women displayed greater sensitivity to pain and feeling of unpleasantness than men . SimilarOn the contrary, male patients show a high level of concern in the fatalism subscale than women. Fatalism is the feeling of hopelessness about pain and its medication . Based oWith regards to the communication subscale, the findings show that women had moderate concerns compared to men. This finding might be due to the different beliefs and attitudes held by women about cancer. Several factors may contribute to barriers in communication among cancer patients such as age, gender, educational level, and ethnicity . The comAnother highlight of this study is the difference of severity in pain between men and women. The findings show that women had a moderate to severe level of pain compared to men. This result was parallel to previous studies in which greater pain severity was found among women than men . AlthougConcerning the factors associated with attitudinal barriers to pain management, it was found that age, gender, marital status, employment status, cancer type, and presence of comorbid disease emerged as significant predictors. This result is in agreement with studies done in China and Jordan which found significant associations between employment status and gender in attitudinal barriers to pain management . This maThe authors acknowledge some limitations of this study. First, due to the small sample size, the result cannot be generalized to the level of pain among all patients with cancer in Saudi Arabia. Future research should investigate in more detail between-gender differences such as in a qualitative study to determine other important attitudinal barriers. However, these findings may serve as initial information that might be useful for future comparison and for health authorities in assessing the differences between men and women in barriers to pain management of cancer patients. We believe that this study may help in developing or enhancing intervention programs to support and reduce pain for cancer patients. Assessing the statistics data acquired from the study, it is highly recommended that pain treatment exercises be proposed and prescribed for patients with cancer. This might also serve as a criterion for good functioning or comparison if it is possible.Managing pain requires the involvement of all methods in a comprehensive manner, thus unalleviated pain influences the patients’ psychological or cognitive aspect. This study revealed that there is a significant difference between gender and attitudinal barriers to pain management of cancer patients, as women tended to have more concerns and feel more intense pain than male patients. Understanding health strategies, accessibility of treatments, and specialized improvement are all fundamentals for optimum management for cancer pain since constant pain is still the main conflict for patients with cancer. Continuous support and additional care is needed particularly among female patients by educating them on pain management that will increase their knowledge and adherence to the treatment as well as eliminating the barriers to pain management. An educational program that will lessen the barriers, particularly any misapprehensions regarding the adverse reaction and consumption of medicines, would be helpful.The study findings identify significant differences between men and women in cancer pain management in Saudi Arabia. Hence, this study supports the development of gender-specific interventions to treat cancer-related pain. Several findings can be drawn from the study which could be used within the guidelines when developing specific interventions in managing cancer-related pain; for example, (a) high level of concern of patients about side effects, (b) fear of addiction, and (c) fear that pain medication can affect their immune system. Educational programs about cancer pain medication may help patients to lessen their hesitancy and fear of drug addiction, and the harmful effects of pain medicine. Healthcare providers such as physicians and nurses should also use screening and assessment tools to ensure medication adherence, and review the patient’s beliefs as part of their usual clinical care. A wrong belief or patient misunderstanding about cancer pain medication may decrease analgesic adherence and this influences pain severity, and results in failure to manage cancer pain. These findings may also guide future studies to elucidate the underlying cause for these specific differences in Saudi Arabia.The dataset used is locked and stored in the College of Applied Medical Science at King Saud University and can be obtained from the author on reasonable request.The studies involving human participants were reviewed and approved by Institutional Board at King Saud University. The patients/participants provided their written informed consent to participate in this study.AA and KA: conceptualization, writing–original draft, and data analysis. NA, TA, WA, and MB: facilitate data gathering and writing–original draft. JV: writing original draft and data analysis. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Objectives: Traumatic hand injuries present to emergency departments frequently. Pain secondary to these injuries is typically managed with opioids, which may be inadequate and have side effects. Ultrasound (US)-guided forearm nerve blocks have emerged as an alternative modality for patients with acute pain from isolated extremity injuries.Methods: We performed a non-blinded, consecutive, randomized pragmatic trial of US-guided forearm nerve blocks using medium and long-acting anesthetic versus usual care for a six-day period around July 4th, 2017. Adults who sustained a traumatic or blast injury of their hands were considered. Consecutive emergency department patients were consented, enrolled and randomized into a study group (block) or control (standard care). The study group received a US-guided forearm block using a 50/50 mix of 1% lidocaine and 0.5% bupivacaine. The primary outcome was median pain scores via a 100-point visual analog scale at 15, 60, and 120 minutes after the nerve block compared to the baseline pain score. The secondary outcome was mean morphine equivalents administered.Results: Sixteen patients were screened and 12 were randomized: six to the treatment group and six to the control group. Median pain reduction from baseline at 15, 60, and 120 minutes in the forearm block group was -35 (IQR=10), -30 (IQR=50), and -20 , -20.5 (IQR=20), -20 (IQR=70) in the control group. At all time points, patient-reported pain scores decreased significantly over baseline in the forearm block group, whereas non-significant reductions in pain scores occurred in the control group.Conclusion: US-guided forearm blocks for acute traumatic hand injuries resulted in greater pain relief when compared to usual care. Hand and forearm pain secondary to fracture, laceration, dislocation, infection, and blast injury is a common issue in the emergency department (ED) . In the In a recent publication, 121 of 171 emergency medicine residencies provided information on the usage of regional anesthesia in the ED with 84% of programs performing US-guided nerve blocks, most commonly forearm nerve blocks . Nerve block techniques are taught via didactic sessions, online resources, and supervised training. Most residency programs do not have specific agreements with other specialty services with regard to performing US-guided nerve blocks in the ED .This study was reviewed and approved (STUDY00001627) by the Institutional Review Board for Human Subjects Research at the University of Washington. Prior to the study, a multidisciplinary group consisting of emergency medicine, orthopedic surgery, and plastic surgery formalized a forearm block protocol. The protocol outlined four key components that would guide patient selection, procedural readiness, and patient safety. First, the hand surgery consultant would provide a timely evaluation of the patient in the ED and perform a standardized hand examination to discern if and when surgery was needed. Second, the ED provider administering the nerve block would reference weight-based local anesthetic dosing to ensure appropriate and safe dosing. Third, we created a “block box” that held all the necessary tools  for the ED provider to have at the patient bedside for the procedure. Finally, we ensured immediate access to lipid emulsion should there be any complication resulting in local anesthetic toxicity.Study design and participantsThis study was conducted at an urban, academic, Level I trauma and burn center with an average of 66,000 annual ED visits. We consecutively enrolled consenting adult patients with trauma to the hand presenting to an academic, Level I trauma and burn center, between July 1 and July 6, 2017. Potential patients were approached consecutively by the study team and were included if they were: 18 years or older, clinically stable, sustained an injury to the upper extremity injury distal to the wrist requiring pain control, and were able to consent. Subjects were excluded if they were: at high risk for compartment syndrome as determined by the primary ED physicians, immediately going to the operating room, requiring emergent interventions for polytrauma, unable to be consented , or incarcerated. Once consent was obtained, the patient was randomized to the treatment arm  or the control arm . The patient received a standardized and detailed hand examination by the hand surgery consultant. If randomized to the treatment arm, the patients were then eligible for US-guided forearm nerve block to be performed by a trained emergency medicine physician study team member (attending or senior resident) in addition to pain management as determined by the primary ED treating team. All study team members had completed training including a didactic session as well as practice performing simulated blocks on a phantom model. A review of the EHR at 30 days after enrollment was performed to assess for complications. This study was performed in a manner consistent with CONSORT criteria . The patient’s forearm was prepped with chlorhexidine and draped in an appropriate sterile fashion. Using a high frequency, linear transducer with a SonoSite X-Porte  fitted with a sterile probe cover, the median, radial, and ulnar nerves were identified in cross-section with ultrasound (US). Using an in-plane needle approach, a 20-gauge spinal needle attached to a 10mL syringe was advanced toward the nerve. Three to five milliliters of a 50/50 mix of 1% lidocaine and 0.5% bupivacaine was infiltrated around the nerve, with care taken not to inject within the nerve. If necessary, standard pain management was allowed for the intervention group per the primary clinical care team.Pain assessmentFollowing randomization, the patient-reported pain scores were recorded (prior to intervention in the nerve block group). Among patients who had bilateral injuries, one side was randomly selected for analysis of pain scores and recorded. Pain scores were assessed independently using a visual analog slider with a scale ranging from 0-100 provided by REDCap  at standardized times of 0 (prior to the procedure), and then 15, 60, and 120 minutes after completion of a nerve block (or randomization in the control group). If the patient was unable to use the slider because of their injuries, they would verbally instruct a family member/friend to move the slider on the scale to reflect their current pain severity.OutcomesThe primary outcome was median pain scores via a 100-point visual analog scale at 15, 60, and 120 minutes after the nerve block compared to the baseline pain score. The secondary outcome was mean morphine equivalents administered.Statistical analysisA Wilcoxon signed-rank test was performed comparing median VAS scores before and after the nerve blocks for each patient. All analyses were performed using Stata 14.2 . A power calculation for the 15-minute group comparison, where we expect to see the largest difference, including the power of 80%, and alpha set at 0.05 was performed prior to enrollment using estimation for a clinically significant reduction in pain severity in accordance with prior studies ,12. UsinCharacteristics of the study cohortSixteen patients were approached and screened for enrollment into the study during the dates July 1 to July 6, 2017. Of these 16 patients, four were not able to be enrolled. Of these four patients, two did not meet inclusion criteria (one patient was taken to the OR and one patient was too intoxicated to consent) and two declined to participate (one patient declined because they did not have pain and the other did not want to be part of the study). A total of 12 patients were enrolled and randomized to the treatment group (N=6) and the control group (N=6). The median age of all enrolled patients was 41 years (19-72) and all were male. Among both groups, nearly all patients arrived by emergency medical services, and the majority of injuries were resultant from a blast mechanism . All blocks were performed by study team members.Main resultsMedian pain reductions in VAS at 15, 60, and 120 minutes after nerve block in the intervention group were -35 (IQR=10), -30 (IQR=50), and -20 (IQR=70), on a 100-point scale compared to baseline. In the control group, median pain reductions in VAS at 15, 60, and 120 minutes after randomization were -5 (IQR=10), -20.5 (IQR=20), -20 (IQR=70) compared to baseline , and non-significant reduction at 60 minutes (p=0.05). One patient in the group reported continued paresthesia at three days post-intervention. No patients had paresthesias at 30 days. No other significant complications were reported.Secondary resultsMME administered for the intervention group was 6mg (IQU 2-12mg) compared to the 13mg in the control group (IQR4/16mg) with a p-value of 0.58. While the control group did receive more IV opioids there was no statistical significance when comparing the two groups.This small randomized trial of patients undergoing US-guided forearm nerve blocks for acute traumatic hand injuries found significant improvement in patient-reported pain and 15 minutes and 120 minutes after the procedure, as compared with non-significant reductions in pain in the control group. The demographics, mode of arrival, mechanism of injury, and injury patterns were similar among the two groups. Fewer IV opioids were administered among the intervention group, although there was no statistical difference.There were no reported adverse events related to the nerve blocks. Collectively, these findings suggest US-guided forearm blocks are feasible and may be an efficacious and safe modality to relieve pain for acute traumatic hand injuries and limit opioid use.Regional nerve blocks have proven a useful tool in the management of extremity pain, and the use of direct visualization with US can minimize risks and provide improved anesthesia of the hand when compared to the landmark-based approaches -16. StudThis study has limitations. First, the total number of patients that met inclusion criteria was small. This was, in part, due to a narrow study design in order to limit the confounding effects of other major painful trauma to other organ systems. Further, the study procedure must not interfere with critically ill or potentially life-saving interventions being provided to polytrauma patients. Second, the study was not blinded to patients, investigators, or the primary clinical care team. Future studies could utilize sham blocks, and effectively blind all parties to the administration of regional anesthetic. Third, outcome reviews were limited to the hospital system in which the patient presented for study enrollment, and therefore may have missed complications diagnosed at outside hospital visits. Finally, it is possible that patients who had more severe injuries might have biased the results; however, we controlled for bilateral injuries by random selection of laterality for pain assessment, as well as performing the analysis of pain reduction between specific subjects as opposed to comparing group means or medians to account for the variability of how individual persons experience and report pain.US-guided nerve blocks have been shown to be an effective pain management modality in the emergency department, specifically, the use of US guided-forearm blocks. These forearm blocks provide the ED physician another tool to manage patients with severe pain in the acute period, such as hand blast injuries. Our study demonstrates that a US-guided nerve block of the forearm gives greater pain control earlier in the course of the patient’s care in comparison to traditional intravenous therapy alone. Early regional anesthesia among patients with hand injuries in ED appears to be effective, feasible, safe and may result in lower opioid use.Additional studies in this area would be beneficial. Studying a larger cohort of patients with painful hand injuries and utilizing a blinded approach  may provide further support for the use of US-guided forearm blocks for painful hand injuries.


Comparing simple vs. advanced technique, neither the complete pain response  nor the partial pain response  was significantly different. There was no significant patient-reported difference in pain interfering with general activity, mood, walking ability, normal work, relationships, sleep, or enjoyment of life. Given that there is increasing utilization of advanced RT techniques, there is further need for randomized trials to assess their benefits given the increased cost and inconvenience to patients.We assessed whether advanced RT techniques were associated with differences in patient-reported outcomes (PROs). Patients with bone metastases who completed the brief pain inventory (BPI) before and after RT were identified, and RT technique was categorized as simple  or advanced , intensity-modulated RT (IMRT), or stereotactic ablative RT (SABR)). Pain response and patient-reported interference on quality of life secondary to pain was compared. A total of 1712 patients completed the BPI. From 2017–2021, the rate of advanced RT technique increased significantly ( Bone metastases (BoM) are common, most often resulting from primary prostate, breast, or lung malignancies . RadiothIn British Columbia (BC), Canada, all RTs are given at BC Cancer, which is provincially coordinated and population-based ,15. In aThe primary objective of this analysis was to assess whether there is a correlation between simple vs. advanced RT techniques for BoM and PRO pain response and pain interference on quality of life (QoL).From 2017–2021 inclusive, patients with BoM who completed the BPI PRO questionnaire at one of five BC Cancer centres before  and after RT (vast majority at 6 weeks post last fraction) were identified, and RT technique was categorized as simple  or advanced . The BPI is a validated tool recommended for use in research assessing pain responses of patients receiving palliative RT [This study was approved by the joint UBC and BC Cancer Research Ethics Board (protocol code H22-00079 approved 1 January 2022).Patient characteristics are presented in The use of advanced RT techniques increased significantly from 2017 to 2021, averaging 5% over the study duration . Most adp = 0.58) at baseline. As shown in Baseline pain by technique did not differ , IMRT , or SABR . Similarly, there was no significant association on multivariable analysis looking at complete response for simple RT (reference) versus 3DCRT , IMRT , or SABR .After controlling for gender, age, primary histology, and treatment region, there was no significant association of RT technique and either partial  or complp values > 0.1). Similarly, there were no significant associations on univariable or multivariable analyses when technique was divided into simple RT, 3DCRT, IMRT, and SABR, though numbers were small in multiple categories.RT technique was also not associated with pain’s impact on QoL upon either univariable or multivariable analysis (This population-based analysis of a publicly funded RT program, where salaried radiation oncologists have no incentives to prescribe more advanced RT techniques, confirmed a continued increase in the use of advanced RT techniques for BoM from the previously published trend . HoweverOur finding of increased use of advanced RT techniques is consistent with other jurisdictions ,18. For A recently completed Canadian and Australian SC.24 randomized phase III trial showed a significantly higher complete pain response from SABR compared to conventional RT . HoweverOur study should be interpreted in the context of its strengths and limitations. As a retrospective study, it is not able to assess causality between RT technique and PROs. Furthermore, the use of SABR was rare and therefore our results should be interpreted most broadly as a comparison between simple techniques and more conformal techniques, rather than a comparison in dose difference between SUPR and SABR. In addition, the use of advanced RT techniques was not randomized, and it is highly likely that more fit patients were offered these techniques over simple RT. However, as a large study from a population-based RT program that routinely collects PROs in patients treated for BoM, it is relatively free from selection bias and has broad generalizability.In this publicly funded, non-incentivized healthcare system, there were no patient-reported differences in pain or impact of pain on quality of life between simple vs. more conformal advanced RT techniques such as 3DCRT and IMRT. Given that there is increasing utilization of advanced RT techniques in our cohort and other jurisdictions internationally ,5,18, th


P < 0.001). The efficacy remained steady till the end of 6 months, with a final remission rate of 88.9%. Sitting time also significantly lengthened following PRF . Only short-term ipsilateral involuntary convulsion of the lower extremity was reported in one patient, who recovered within 12 h. Six patients were treated with nonsteroidal drugs for a short time. All patients stopped taking medication finally. In conclusion, the ultrasound-guided high-voltage long-duration PRF approach not only reduced the pelvic pain caused by PN but also improved the quality of life by extending sitting time without nerve injury.Pudendal neuralgia (PN) is a complex disease with various clinical characteristics, and there is no treatment showing definite effectiveness. This study is aimed at evaluating the clinical efficacy of ultrasound-guided high-voltage long-duration pulsed radiofrequency (PRF) for PN. Two cadavers  were dissected to provide evidence for localization of the pudendal nerve. Patients diagnosed as PN who failed or were intolerant in regular medication were screened for diagnostic local anesthesia block of the pudendal nerve before recruitment. Twenty PN patients were enrolled in this study. In the PRF procedure, the needle tip was inserted medially into the internal pudendal artery under ultrasound guidance. The position of the PRF needle tip was then adjusted by the response of the pudendal nerve to the electrical stimulation within the pudendal area . Alleviation of pain was assessed by the visual analogue scale (VAS) and sitting time pretreatment and on 7 d, 14 d, 1 m, 2 m, 3 m, and 6 m posttreatment in outpatient follow-up or by telephone interview. Two patients were lost due to intervention-irrelevant reasons. Patients showed significantly decreased VAS scores on 7 d after RFP, compared with pretreatment status (7.0 ± 0.9 vs. 3.2 ± 1.7,  Pudendal neuralgia (PN) refers to neuropathic pain in the pudendal nerve innervation region, which may occur in the entire perineal region or in one of its branches, and is often accompanied by symptoms such as rectal and anal foreign body sensation, distension, frequency and urgency of urination, and sexual dysfunction , 2. AccoRadiofrequency has been used to treat pain for nearly a century. It is widely applied to regions including the head, neck, chest, waist, and sacral region –9. HowevCompared with other image-guided technology, ultrasound is playing an increasingly important role in pain diagnosis and treatment due to its advantages of radiation-free, convenient, and real-time positioning guidance –19. UltrTwo adult cadavers  formalin embalmed and fixed were used . The cadaver specimens had intact pelvis and pelvic organs. The subcutaneous tissues and muscles of the buttock were opened layer by layer to expose the subgluteal space, the sacrospinous ligament, and its adjacent vessels and nerves. The anatomical relationship between the sacrospinous ligament and the pudendal nerve was confirmed.Patients diagnosed as PN who received treatment were recruited from the pain center of Changhai Hospital from Sep 1, 2015, to Oct 31, 2016. The PN diagnosis was based on the Nantes criteria  [1]. TheInclusion criteria are as follows: (1) aged from 18 to 80 years old and no sex limitation; (2) patients who were not satisfied with conservative treatment or intolerant to the side effects; and (3) be able to sign an informed consent form. Exclusion criteria are as follows: (1) patients with pelvic organic disease that may also cause pain in the pudendal region; (2) patients with malignant or autoimmune diseases that cause pain; (3) pregnant women; (4) patients with any coagulation disorder; and (5) patients who are unable to complete the outpatient or telephone interview.Effective pudendal nerve block is an essential approach for the inclusion of patients. The patient was in the prone position, and a low-frequency curved-array probe  was used to scan from the posterior superior iliac spine downwards to the transverse section of the ischial spine Figures . The intIn the PRF procedure, the patient was placed in the prone position on a sterilized sheet with routine disinfection. A 20 G radiofrequency needle (Cosman) was used for puncture, and the puncture process was the same as the diagnostic block of PN Figures .In the sensory test (50 Hz), when the voltage was 0.3-0.5 V, the patient could feel the tingling sensation at the pain site, which indicated that the puncture needle tip was around the pudendal nerve. When the voltage was higher than 2 V in the motor test (2 Hz), the lower limb movement of the same side was not induced, indicating that the puncture needle tip was far from the sciatic nerve. During PRF, the radiofrequency instrument was set as the manual pulse treatment mode, and the RF parameters were set as follows: temperature 42°C, stimulation frequency 2 Hz, pulse width 20 ms, and duration 900 s; the field intensity began at 40 V and gradually increased until the patient has an intolerable abnormal sensation (such as burning sensation) in the pain site (the intensity was not more than 80 V to avoid nerve damage caused by high temperature). Patients with bilateral pain were treated with bilateral PRF. The procedure was performed with the radiofrequency therapeutic apparatus .Through outpatient or telephone follow-up, the pain intensity of patients was evaluated before intervention and on 7 d, 14 d, 1 month, 2 months, 3 months, and 6 months after high-voltage long-duration PRF treatment. The visual analogue scale (VAS) was applied for pain assessment, with 0 indicating no pain, 1-3 mild pain, 4-6 moderate pain, and above 7 severe pain. The patients' maximum sitting time before the onset of pain  was evaluated according to the assessment method and criteria of previous studies , 21. BriX ± SD). Repeated-measures one-way ANOVA was used for within-group comparison and Bonferroni's test for between-group comparison. P < 0.05 was considered statistically significant. SPSS 22.0 software was used in the statistical analysis.The measurement data were expressed in terms of mean ± standard deviation (2) and one Asian woman .Two cadaver specimens  were examined, including one Asian man  . Seven pP < 0.05). The VAS score did not significantly change since day 14 after treatment  was significantly lower than that before treatment , part of the assessments was completed under the guidance of the same physician through telephone interview. Compared with pretreatment (30 ± 15 min), sitting time significantly prolonged on 7 d (62 ± 20 min), 1 m (81 ± 34 min), 2 m (83 ± 36 min), 3 m (84 ± 39 min), and 6 m (85 ± 37 min) after treatment was significantly longer than that before treatment (30 ± 15 min). However, there was no significant difference in the sitting time among 7 d, 14 d, 1 m, 2 m, 3 m, and 6 m after treatment  is usually ineffective. With the continuous development of image-guided technology, interventional treatment has been increasingly performed by clinicians, especially by pain practitioners. Interventional treatment  has been applied in the treatment of PN , 20, andRadiofrequency technology is a novel technology to treat chronic pain. Traditional continuous radiofrequency technology damages nerves to treat pain in the dominant area, which would inevitably lead to permanent nerve injury and serious side effects. Compared with traditional continuous radiofrequency thermocoagulation technology, pulsed radiofrequency is a nonneurodegenerative radiofrequency technology. The temperature of the electrode tip does not exceed 42°C, which will not cause irreversible tissue damage, in which situation the sensorimotor functions of the nerve could be largely preserved.However, the underlying mechanism of pulsed radiofrequency in the treatment of neuropathic pain is mostly unknown. Some studies suggested that low-temperature pulsed radiofrequency can form a field effect around the lesion, thus regulating the transmission of pain signals . CompareAnatomically, the pudendal nerve goes tortuously and is largely varied. A study showed that before entering the pudendal canal, the branch of the pudendal nerve, the inferior rectum nerve, often runs inward and downward . Even unWith the internal pudendal artery companied, the pudendal nerve is located on the surface of the sacrospinal ligament. When it goes down into the pudendal canal, its branches are more dispersed, and its relative location to the internal pudendal artery may be varied. Therefore, the pudendal nerve is more accessible in the transverse section of the sciatic spine. Previous studies suggested that the pudendal nerve is adjacent to the sciatic nerve above the cross-section of the sciatic spine, which indicated that the sciatic nerve and even the sacral plexus could be involved if penetrating above the cross-section of the sciatic spine. Therefore, punctuation is recommended to locate at the entrance of the pudendal nerve canal. This provided important information for improving ultrasound-guided treatment for PN .Brusciano et al. reported a novel approach, the dynamic transperineal ultrasound (DTU), in the assessment of the pudendal nerve motility , 36. By The present study suggested that high-voltage long-duration PRF treatment can alleviate the pain of patients with pudendal neuralgia and improve their quality of life by prolonging the sitting time without obvious severe adverse events. Ultrasound-guided PRF could be a safe and rewarding treatment for PN patients.


Many patients with postpolio syndrome (PPS) experience pain. In this study, we aimed to review previous studies to investigate the effectiveness of intravenous immunoglobulin (IVIG) for managing pain in patients with PPS. We performed a narrative review.  In PubMed, we searched for the keywords ((Immunoglobulin OR IVIG) AND (poliomyelitis OR poliomyelitis syndrome)). We included articles in which IVIG was infused in patients with PPS and pain severity was measured before and after treatment.  In the results, five articles  were included in this review. Four of the studies reported that IVIG had a positive pain-reducing effect in patients with PPS. In addition, 4 studies evaluated the outcomes related to muscle strength and function. Of these studies, 3 showed some improvement in measurements for muscle strength and function.  In conclusion, IVIG might be one of the beneficial options for managing pain in PPS. Pain reduction might be responsible for the improvement of muscle strength or function. To confirm the benefits of IVIG in reducing pain, more high-quality studies are required. Postpolio syndrome (PPS) was reported in survivors from acute poliomyelitis infection . The prePain is one of the common complaints of patients with PPS, which decreases quality of life and hinders activities of daily living –9. The mThe degree of pain from PPS is moderate to severe . For manHere, we reviewed previous studies to investigate the effectiveness of IVIG for managing pain in patients with PPS.Two authors (D. P. and M. C. C.) independently performed a literature search in PubMed. Differences in their search results were resolved through a discussion. The keywords used in the search were ((Immunoglobulin OR IVIG) AND (poliomyelitis OR poliomyelitis syndrome)). The search was limited to articles published up to June 27, 2020. The following inclusion criteria were applied for the selection of articles: (1) IVIG was infused in patients with PPS, (2) pain severity was measured before and after treatment, and (3) written in English. We excluded case reports and reviews. Data were extracted by two independent reviewers (D. P. and M. C. C.).A total of 1,941 potentially relevant articles were found in the primary literature search. After reading the titles and abstracts and assessing them for eligibility based on the full-text articles, 5 articles were finally included in this review . Of the The first study on the pain-reducing effect of IVIG in patients with PPS was performed by Gonzalez et al. in 2006 . They reIn contrast to the study of Gonzalez et al. , the othγ and IL-23 levels in cerebrospinal fluid were decreased in the IVIG group.In 2012, Gonzalez et al.  recruiteIn 2013, Bertolasi et al. [In another prospective observational study, Werhagen and Borg  demonstrOf the 5 previous studies , 18–20, The mechanism of pain reduction of IVIG in patients with PPS has not been clearly elucidated. However, we propose some possible mechanisms. The levels of several cytokines are increased in the cerebrospinal fluid of patients with PPS, which activates microglia and macrophages, generating noxious effects on neural cells by producing nitric oxide, protease, and glutamate products , 21. IVIThe 5 previous studies that evaluated the pain-reducing effect of IVIG did not investigate nociceptive pain and neuropathic pain separately , 17–20. In conclusion, this review shows that IVIG administration might be useful for managing pain in patients with PPS. In the 5 articles reviewed, no major adverse effects were reported. Owing to the small number of studies and inconsistent results between the studies, we cannot make a definite conclusion on the effect of IVIG on pain in PPS. However, we think that the previous studies showed a possibility that IVIG can safely manage pain in patients with PPS. To confirm the benefits of IVIG in reducing pain in patients with PPS, more high-quality studies are required. Moreover, the protocols for IVIG infusion used in each study were heterogeneous; therefore, the most effective protocol for IVIG infusion for controlling pain should be evaluated in the future.