This study aimed to present the different pattern of intravertebral vacuum cleft (IVC) related to high risk of cement complications in minimally invasive treatments for Kümmell's disease (KD) and relevant treatment strategies.A retrospective study from January 2016 to January 2018 was conducted at Wuhan Fourth Hospital and comprised 35 patients with Kümmell's disease. There were seven males and 28 females, and the mean age of the patients was 70.4 years. The patterns of IVC in KD were analyzed. These patients were divided into three groups based on the treatment method used. The treatment methods included long‐segment fixation (LSF), posterior short‐segment fixation (SSF), and percutaneous kyphoplasty (PKP). We retrospectively reviewed outcomes, including the Oswestry Disability Index (ODI), visual analog scale (VAS) score, anterior height of affected vertebrae, kyphotic Cobb angle, and complications.P < 0.05). In PKP group, although the VSA and ODI showed statistically significant differences between pre‐ and post‐operation and between pre‐ and final follow‐up (P < 0.05), we could observe that the VSA and ODI rebounded a little at the final follow‐up. Cement leakage into intervertebral space occurred in four (44.45%) patients of PKP group.All patients were followed up for 12–38 months. According to their radiographic appearance we could observe two main patterns of clefts. Pattern I, clefts that were found to be near to the endplate and connected with intervertebral space, the endplate was incomplete. Pattern II, IVC traversed to anterior edge of the vertebral body affected. Both were related to high risk of cement complications in minimal invasive treatments for KD. Good results have been achieved in LSF and SSF groups, the VAS, ODI, anterior height of affected vertebrae and kyphotic Cobb angle showed statistically significant differences between pre‐ and post‐operation and between pre‐ and final follow‐up (PKP should be chosen carefully if the IVC of the patient presents to be pattern I or II. LSF and SSF are safe and effective, and can achieve satisfactory correction of kyphosis and vertebral height, with pain relief and improvement in patient's daily life, with few complications. Following the accelerated speed of population aging, osteoporotic vertebral compression fracture (OVCF) has become increasingly common. Among which the incidence of nonunion is approximately 13.5% and the incidence of intravertebral vacuum cleft (IVC) sign is about 7%–13%In 1895, German surgeon Hermann Kümmell first reported six patients with delayed posttraumatic vertebral collapse after minor trauma, which was referred to as KDet al.et al.Up to now, there are several studies on classification and staging of KD, all according to the disease's progression. Dr Steel divided KD into five stages according to the development of symptoms. Stage 1 is the initial insult with no abnormality on the X‐ray. Stage 2 is the post‐traumatic period of minor back pain. Stage 3 represents the latent interval of relative well‐being; patients in this stage usually experience asymptomatic period lasting from months to years. Stage 4 means the recrudescent stage; patients may feel progressive pain at the fracture position. Stage 5 is the terminal stage; patients may suffer permanent kyphosis or compression of roots and spinal cord in this stageNo standard or single effective treatment for Kümmell disease exists. In general, conservative treatments have usually been less effective, and carry a risk for delayed neurological deficitsBy referring to various articles, combined with our experience on treatment of the disease, we recognized that the cement leakage, extravasation or dislodge of PVP/PKP has relation with the pattern of IVC in the vertebral body, rather than the stage of the disease. Therefore, this retrospective study aimed to provide surgeons with: (i) the different patterns of IVC related to the high risk of cement complications in minimally invasive treatments for KD; (ii) useful and reasonable treatments to reduce the incidence of cement complications; and (iii) classification and treatment strategies of KD based on the different patterns of IVC rather than the stage of the disease.The patterns of IVC in KD were analyzed. Patients were divided into three groups based on the treatment method used. The treatment methods included long‐segment fixation (LSF), posterior short‐segment fixation (SSF), and percutaneous kyphoplasty (PKP). We retrospectively reviewed outcomes, including the Oswestry Disability Index (ODI), visual analog scale (VAS) score, anterior height of affected vertebrae, kyphotic Cobb angle, and postoperative complications.Each patient provided informed consent for participation in the study. This retrospective study was conducted in accordance with the Declaration of Helsinki  and was approved by the Ethics Committee of the Wuhan Fourth Hospital, Huazhong University of Science and Technology.From January 2016 to January 2018, the inclusion criteria were as follows: (i) had a history of minor trauma or had no memorized accident; (ii) back pain weeks to months after the initial minor traumatic injury; (iii) IVC signs on simple lateral radiographs and computed tomography (CT) or evidence of osteonecrosis with a fluid sign on magnetic resonance imaging (MRI); and (iv) conservative treatment failed to relieve the pain. Exclusion criteria: (i) congenital lumbar scoliosis, spinal stenosis, or other deformities; (ii) pathologic vertebral compression fractures from spinal metastatic cancer, osteolytic bone tumors, and hemangioma; and (iii) a history of previous vertebroplasty or spinal surgery. Finally, 35 KD patients  were included.All the pre‐ and postoperative radiographs of these patients at our medical center were analyzed retrospectively.All patients underwent plain film, dynamic x‐ray, computed tomography (CT) scans, and magnetic resonance imaging (MRI).The mean age of the patients was 70.4 years, ranging from 61 to 84 years. The patients had different degrees of osteoporosis, and the lumbar spine bone mineral density T score (BMD) ranged from −2.9 to −4.4, with a mean of −3.5 ± 0.8. Eight participants had no memorized accident, while the other 27 presented minor trauma, including sprain (13 cases), tumble (seven cases), fall (five cases) and bruise (two cases). There were 38 vertebral bodies affected, with three patients being double‐level vertebral affected, and 91.43% were single‐level vertebral‐body affected cases. All patients presented intractable back pain. The timing of back pain ranged from 1 month to 9 months, with an average of 4.3 months. Changes in position induced or aggravated the pain, which could not be relieved by bed rest or regular medical treatment with drugs (such as Celecoxib) for 3 months. All patients were followed up for 12–38 months.According to their radiographic appearance, we could observe two main patterns of clefts: Pattern I, clefts that were found to be near to the endplate and connected with intervertebral space, the endplate was incomplete; and pattern II, IVC traversed to anterior edge of the vertebral body affected. These patterns are shown in Fig. The general principle of treatment for KD was to enhance and support anterior column, and to fix and stabilize posterior column. The treatment methods included open surgery and minimally invasive treatment; the former included posterior long‐segment fixation (LSF) and posterior short‐segment fixation (SSF) based on the different condition, while the latter referred to PKP according to our therapeutic experience in this study.Basically, LSF was performed in all type A patients, while SSF and PKP were optional in type B patients. Type B patients decided themselves which treatment to choose after being fully informed of the advantages, disadvantages and complications of these two treatment methods, respectively.Then the 35 patients were divided into three groups  based on the surgical method used.The patients in the LSF group received general anesthesia and were placed in a prone position. A posterior midline approach was used to expose the spinous processes, lamina, and facet joint; eight or 12 pedicle screws were inserted bilaterally into two or three levels above and below the affected vertebra. Decompressive laminectomy of the diseased vertebra was applicable if patients had neurologic deficits; pedicle subtraction osteotomy (PSO) or Ponte osteotomy was applicable to correct the kyphotic deformities; cement‐augmented pedicle screws were used to address the high risk of internal fixation failure according to severe osteoporosis. Calcium sulfate with BMP  was injected slowly into the diseased vertebra by cannula and trocar systems to fill the IVC to enhance the anterior column, and this process was monitored under fluoroscopic control in the lateral plane. After that, pedicle screws were fixed with two rods, which were used to achieve further recovery of the vertebral height. Long‐segment fixation was used to restore sagittal balance and stabilize the spinal column. Autogenous bone grafts from the decompression laminectomy were used to facilitate posterolateral fusion. Crosslinks were used in all patients. The incision was rinsed and hemostasis achieved, then was sutured hierarchically  was injected slowly into the affected vertebra like the procedure described in LSF. After that, pedicle screws were fixed with two rods, which were used to achieve further recovery of the vertebral height. Decompressive laminectomy of the diseased vertebra was performed for patients with neurological deficits. Posterolateral fusion was performed by the application of allograft bone. The incision was dealt with by the same procedure described in LSF Fig. .The patients in the PKP group received local anesthesia  and were placed in a prone position. A transpedicular approach was performed with trocar and cannula systems under biplanar fluoroscopic guidance. The expandable balloon was placed into position. The ideal position of the top of the needle was laterally positioned in the first quarter of the interior of the affected vertebrae and the channel went through IVC. The balloons were expanded up slowly to the expected effect of vertebral reset and to create a cavity for the injected cement. Polymethyl methacrylate (PMMA) cement was injected into the cavity within the vertebral body when it became doughy and could stand at the tip of the bone cement inserter. The injection process was monitored continuously under fluoroscopic control in the lateral plane. The procedure was stopped immediately if high resistance was encountered or if PMMA neared the posterior wall of the vertebral body. The amount of cement was generally 4–8 mL. We continued to observe the distribution of the bone cement in the vertebrae. The curing time of bone cement was 15 min, and after waiting sufficient time and confirming bone cement curing, we turned and pulled out the pipe. The patients were kept at bed rest for 1 day after the procedure  questionnaire. The visual analogue scale  system was employed to evaluate back pain control. All patients were evaluated preoperatively, at 7 days postoperatively, and at the final follow‐up.The ODI is one of the principal condition‐specific outcome measures used in the management of spinal disorders. For each section of six statements, the total score is five (the first statement is marked with the score “zero” and the last statement is marked as “five”). If more than one box is marked in each section, the highest score is taken. If all 10 sections are completed, the score is calculated as follows: total scored/50  × 100%. If one section is missed (or not applicable), the score is calculated as: total scored/45  × 100%. Therefore, the final score may be summarized as: [total score/(5 × number of questions answered)] × 100%. Rounding the percentage to a whole number is suggested for convenience. We defined that: 0%–20% means mild; 21%–40% means moderate; 41%–60% means severe; 61%–80% means very severe; and 80%–100% means patients with very exaggerated symptoms.The VAS score system is used in the social and behavioral sciences to measure low back pain and leg pain. The VAS pain scoring standard (scores from 0 to 10) was as follows: 0 means painless; 1–3 means mild pain that the patient could endure; 4–6 means the patient was in pain that could be endured and was able to sleep; and 7–10 means the patient had intense pain and was unable to tolerate the pain.All patients underwent plain film, dynamic x‐ray, CT scans, and MRI. The anterior height of the affected vertebrae along with the kyphotic angle was measured on a lateral x‐ray. Cobb's methods were used to measure the kyphotic angle of the affected vertebrae. Dynamic X‐ray was used to access spine dynamic instability, which was defined as the difference of Cobb angle during dynamic radiography greater than 10°. All of the foregoing data were evaluated preoperatively, at 7 days postoperatively, and at the final follow‐up. Complications were recorded as well.t‐test or one‐way ANOVA. Count data, including sex and damaged segment, were compared using chi‐square test or Fisher exact test. A P value <0.05 was considered to indicate a statistically significant difference.All analyses were performed using SPSS for Windows, version 19.0 . All measurement data were expressed as mean and standard deviation (SD). Preoperative and postoperative measurement data, including VAS, ODI score, anterior height of fractured vertebrae, and kyphotic Cobb angle were compared using paired There were 20 pattern I and 15 pattern II patients respectively. No statistically significant difference was observed in the general data  between these two IVC patterns  patients of PKP group; among them, three patients had recurrent lower back pain during the 3–9 months after the procedure. Their pain were all tolerable and could be relieved by bed rest or regular medical treatment with drugs, VAS score was 3 to 5. No obvious bone cement displacement occurred during the follow‐up. There was no loosening, displacement, or fracture of internal fixation at the final follow‐up. No neurologic deterioration was seen after the surgery.KD is defined as delayed post‐traumatic vertebral collapse after a minor spinal trauma and often occurs in patients with osteoporosis, advanced age, or those undergoing long‐term steroid therapy. Single vertebral body is involved commonly and the most common fractured and necrotic vertebral body is located in the thoracolumbar junctionWhile initially KD was thought to be exceedingly rare, its prevalence is increasing with our aging and often osteoporotic population, and our recognition of this disease. Up to now, there is not yet a consensus reached on classification and corresponding treatment options for KD. Traditionally, KD could be divided into three stages according to clinical symptoms, radiographs, MRI and the progression of the diseaseHowever, this management of KD remains controversial and there are no strict guidelines of treatment strategies for work‐up or treatment. Some authors have reported that PVP/PKP was found to be a minimally invasive and effective procedure that provides pain relief and stabilization of spinal instability associated with KD, even in the late stage of the disease with severe spinal stenosisBy referring to various research, combined with our experience with the treatment of the disease, we recognized that what is even more concerning is the pattern of IVC in the vertebral body, rather than the stage of the disease. In this study, we observed and summarized the different performance of IVC from 35 KD patients, and noted two main patterns of clefts that existed.et al. noted that the IVC and intradiscal vacuum cleft often co‐exist, and a communication channel could be observed between themet al.Pattern I, clefts that were found to be near to the endplate and be connected with intervertebral space, the endplate was incomplete. In this pattern, cement is difficult to disperse throughout the cleft, but easily leaks into the intervertebral space through the cleft for the integrity of the endplates were destructed, which may cause discogenic back pain later on. As showed in Fig. et al.Pattern II, intravertebral vertical clefts traversed to anterior edge of the vertebral body affected. Most cases of this pattern are very dynamic and unstable, for the nonunion runs through the anterior column, even the anterior and middle columns, and lets the remaining rear structure of the vertebrae to possibly act as a hinge when the spine flexes forward and extends backward. Kyphosis in this pattern usually exacerbates when the patient stands up and alleviates when they lie flat. Cement may leak out of the vertebral body through the cleft, or may dislodge forward as a whole in the future. This process was well demonstrated in a case report by Zhang et al.Huang The pattern of IVC is a vital factor, but not the only factor that should be considered in treating KD during the clinical practice. The following conditions should be taken into consideration when a KD patient is under therapy selection: neurological deficits requiring decompression, Kyphosis deformity requiring correction (Cobb angle greater than 30°), or dynamic instability (the difference of Cobb angle during dynamic radiography greater than 10°) requiring fixation operation. In this study, if the patient had any these conditions, they would be defined as type A; if intractable back pain was the only complaint without any of these conditions, they would be defined as type B. The general principle of treatment for KD was to enhance and support anterior column, and to fix and stabilize posterior column. The treatment strategies were as described above; in brief, LSF was performed in all type A patients, while SSF and PKP were optional in type B patients. Good results have been achieved in LSF and SSF groups. There were no serious intraoperative or postoperative complications, no loosening, displacement, or fracture of internal fixation at the final follow‐up, no neurologic deterioration was seen after the surgery. LSF and SSF are safe and effective for treating KD, and can achieve satisfactory correction of kyphosis and vertebral height, with pain relief and improvement in patient's daily life, with few complications.P < 0.05), we could observe that the VSA and ODI rebounded a little at the final follow‐up. This resulted in the differences between postoperative and final follow‐up values, which were also statistically significant (P < 0.05). We recommend that PKP should be chosen carefully if the IVC of the patient presents to be pattern I or II.But in PKP group, cement leakage into intervertebral space occurred in four patients; among them, three patients had recurrent lower back pain 3–9 months after the procedure. Although the VSA and ODI showed statistically significant differences between pre‐ and post‐operation and between pre‐ and final follow‐up (This study is limited in that the number of cases included was not enough, and more cases should be included in further research. Except for the patterns of IVC indicated in this study, other patterns of IVC might be discovered according to more cases. In addition, this is a retrospective study, and financial factors and preoperative medications may have influenced the result of this study.There are two main patterns of IVC related to the high risk of cement complications in minimally invasive treatments for KD. LSF and SSF are safe and effective for treating KD and can achieve the satisfactory correction of kyphosis and vertebral height, provide pain relief and improvement in patient's daily life, with few complications. PKP should be chosen carefully if the IVC of the patient presents to be pattern I or II. However, the performance of IVC in KD should be observed in more patients in the future study, and the long‐term clinical outcomes and radiological results require further evaluation.


Subgroup analysis showed that EMLA did not significantly reduce pain when the patients took an analgesic premedication  with a heterogeneity of I2 = 38% (P = 0.52). Conversely, studies without premedication showed a significant pain relief effect  with a heterogeneity of I2 = 48% (P = 0.14). Most studies showed there was no difference in the patient’s need for analgesics. EMLA was effective for reducing pain during EWSL. However, this analgesic effect was limited and did not reduce the need for analgesics.A systematic review and meta-analysis was conducted to explore the effect of a eutectic mixture of local anaesthetics (EMLA) on pain reduction during extracorporeal shockwave lithotripsy (ESWL). PubMed, Web of Science, Embase, EBSCO, and Cochrane library databases (updated March 2020) were searched for randomised controlled trials (RCTs) assessing the effect of EMLA for patients that underwent ESWL. The search strategy and study selection process were managed according to the PRISMA statement. Six RCTs were included in the meta-analysis. Overall, the results indicated that EMLA significantly reduced pain compared to the control group  with a heterogeneity of I Urinary stone disease is the third common disease in the urinary tract which affects 1–5% of the population in Asia, 5–9% of the population in Europe, and 13% of the population in North America .The advantages ESWL are that it is minimally invasive, lacks severe side effects, does not require the use of general anaesthesia, and is economical. Therefore, it has gained widespread acceptance and use for treating uncomplicated stones in certain areas of the kidney. However, the issue that affects patients the most is pain and anxiety after ESWL sessions. According to previous studies, pain may be the result of two factors. The primary source is the increased pressure within the kidney and the other is due to the ESWL-related trauma of the skin and muscles and the stretching of the surrounding renal capsule , 4. FurtEutectic mixture of local anaesthetics  is commonly used as a local anaesthetic topical cream. This cream penetrates the skin up to a depth of 4 mm and the onset time is 10–20 minutes and provides pain relief for up to 60 minutes . Its effWe systematically searched PubMed, Embase, Web of Science, EBSCO, and the Cochrane library up to March 2020 with the following keywords: “topical anaesthetics”, “eutectic mixture of local anaesthetics”, “pain”, and “shock wave lithotripsy”. The list of retrieved studies and relevant reviews were assessed manually and the process was repeated several times to ensure that all eligible studies were included. All processes were in accordance with the Cochrane Handbook . InclusiBaseline information was extracted from the original studies and included the following: first author, published year, number of patients, patient age and gender distributions, description of calculus, and specific usage of EMLA. Data were independently extracted by two investigators. Discrepancies were resolved by consensus.The methodological quality of each RCT was assessed according to the Jadad scale, which comprises of the following three evaluation elements: randomisation (0–2 points), blinding (0–2 points), and dropouts and withdrawals (0–1 points) . One poi2 statistic with I2 > 50% taken to indicate significant heterogeneity [Risk ratio (RR) with 95% confidence interval (CI) was calculated for dichotomous outcomes. Study heterogeneity was evaluated using the Iogeneity . Sensitiet al., patient received an intramuscular injection of 75 mg meperidine hydrochloride and an oral dose of 5 mg diazepam as premedication 30 minutes before ESWL. Meperidine and diazepam were given intravenously if patients still reported pain during procedure [et al. administered 2 mg midazolam I.V to all patients before ESWL then provided intraoperative alfentanil during ESWL when required to further suppress discomfort [et al. received either metoclopramide 10 mg or droperidol 1 mg as premedication and were then provided with alfentanil during the procedure [et al. used remifentanil as the intraoperative analgesics [et al. and Tritrakarn et al. did not supply their patients with any pain medication [In total, 162 articles were initially identified from the databases. After removing duplicates, 101 articles were retained. Then 92 studies were excluded from our study due to unrelated abstracts and titles. We also excluded from our analysis: one article for its study design (not RCT), one articles for insufficient data, and one article for inconformity of outcomes. Finally, six RCTs that satisfied the inclusion criteria were enrolled in this meta-analysis –17. The rocedure . Monk etscomfort . The patrocedure . The rem2 = 57%  at the end of the session  . We appl, et al. . After ret al., Ganapathy et al., and Acar et al. demonstrated that the dosage of analgesics required did not reduce following EMLA [et al. showed that there was a significant reduction in the number of patients who needed additional analgesics and also reported a decreased dosage of analgesics and sedative drugs [Four RCTs reported data on analgesic requirement. However, different kinds and dosages of analgesics were provided and the data could not be analysed. Monk ing EMLA , 13, 14.ve drugs .et al. showed that decreasing discomfort and reassuring the patient are important for the success of repeated sessions of ESWL [EMLA cream is a local anaesthetic and has been proven to effectively relieve pain with few complications in both children and adults since the 1990s. It has a wide range of applications in some outpatient urological and andrological procedures . In addi of ESWL . Thus, m of ESWL . Our syset al. [et al. [et al. also did not observe significant differences in the reduction of pain and analgesic requirement. However, their sub-analysis of the energy level of the shock waves showed that EMLA was not effective at low energy levels of 10, 12, and 15 kV but did significantly reduce pain at higher energy levels of 18 and 20 kV. Dividing the patient population by gender additionally revealed that EMLA was only effective in males. However, their sample size was likely too small to provide conclusive evidence. Therefore, the authors concluded that EMLA does not reduce the need for analgesics nor does it replace the effects of analgesics [Our result suggested that there was a very limited analgesic effect of EMLA. Interestingly, a study by Tritrakarn and colleagues showed that both EMLA and placebo cream provided anaesthetic effect compared with no intervention . Therefoet al. , 24. Acc [et al. . The autalgesics . This fialgesics . AccordiTo the best of our knowledge, this is the first systematic review and meta-analysis investigating the impact of EMLA on pain control during ESWL. Several limitations remain in this study. Firstly, the characteristics of stones including stone size, position, composition, and severity of obstruction, which may affect the pain level of the procedure, were not subject to subgroup analysis. Secondly, different ESWL machines cause different pain and noise which also bring the impact on results. Lastly, missing and unpublished data led to bias in the true impact of EMLA.In conclusion, the results of this systematic review showed that topical use of EMLA was effective for reducing pain during EWSL. However, this analgesic effect was limited and did not reduce the need for analgesics.S1 Checklist(DOC)Click here for additional data file.


Background and objectives: Even though pain in multiple sclerosis (MS) patients is common and possibly associated with reduced quality of life, its exact prevalence and characteristics remain vaguely understood. We aimed to estimate the true extent of pain and its associations with quality of life in Lithuanian MS patients and to compare this data with that of a control group. Materials and Methods: Data were collected prospectively at the Department of Neurology, Lithuanian University of Health Sciences Kaunas Clinics. A face-to-face structured interview and a questionnaire were used to collect demographic and clinical data of the MS (n = 120) and control (n = 120) groups. The Expanded Disability Status Scale (EDSS) was used to quantify disability in the MS group. Scores ≥4/10 in the Douleur Neuropathique 4 questionnaire were classified as neuropathic pain. Patients were evaluated using the anxiety and depression subsets of the Hospital Anxiety and Depression Scale (HADS-A and HADS-D), the physical and mental component subsets of the Short Form-12 questionnaire (PSC-12 and MSC-12). Results: The MS and control groups did not differ in pain prevalence  or intensity. Lhermitte sign, lower limb, and face pain were more common in the MS group, whereas subjects in the control group were more often affected by lower back, neck, and joint pain. Neuropathic pain and pain lasting longer than 2 years were more common among pain-affected MS patients than among controls. MS patients with pain had higher EDSS, HADS-D, and HADS-A and lower PSC-12 scores than those without pain; however, no difference was found regarding the duration of MS or age. Males with MS and pain had higher MSC-12 and HADS-D scores in comparison to the same subset of females. Conclusions: Pain affects approximately three out of four patients with MS in Lithuania and is negatively associated with the mental and physical aspects of quality of life. Pain is a common and significant symptom of multiple sclerosis (MS) that should not be dismissed, as it is rated as one of the highest priorities by individuals with MS, even surpassing functions such as speech or bowel and bladder control . Howevern = 120) was composed of patients diagnosed with MS according to the 2010 and 2017 McDonald criteria [n = 120). All participants were >18 years old. Informed consent was obtained. The study was approved by the Lithuanian University of Health Sciences Bioethics Committee .Data were collected prospectively at the Department of Neurology, Lithuanian University of Health Sciences Kaunas Clinics. The MS group . The study subjects were presented a graphic outline of the body and were asked to mark the areas where they were experiencing pain. Patients were asked to separately report the intensity of the pain experienced at the time of assessment and the average intensity of pain experienced on the day before assessment. The Numeric Rating Scale (NRS-11) from 0 to 10 was used to evaluate the intensity of pain. The Douleur Neuropathique 4 (DN4) questionnaire was used to distinguish nociceptive and neuropathic pain: scores ≥4/10 were classified as neuropathic pain. The Hospital Anxiety and Depression Scale (HADS) was used to determine anxiety (HADS-A) and depression (HADS-D) levels: ≤7—normal; 8–10—borderline abnormal, possible mild anxiety or depression; ≥11—clinically significant anxiety or depression. The quality of life was assessed by using the Short Form-12 (SF-12) questionnaire and separately noting the scores of the physical component scale (PSC-12) and the mental component scale (MSC-12). p values are two-sided; p < 0.05 was regarded as statistically significant. Statistical analyses were performed using IBM SPSS Statistics for Windows, version 25.0 . Descriptive statistics were calculated. Data normality was assessed using histograms and the Shapiro–Wilk test. All variables were non-normally distributed; therefore, Mann–Whitney U test was used to evaluate the differences in continuous variables between the groups. Differences in categorical variables were assessed using the Fisher’s exact and chi-square tests. Data are presented as median (interquartile range) or number (percentage), unless indicated otherwise. Correlation was analyzed using Spearman’s rank correlation test. All n = 119) were diagnosed with relapsing–remitting MS. Males had slightly higher EDSS scores than females (3.5 (2.4–4.5) vs. 2.5 (1.5–3.5), p = 0.021), no other differences between the genders in the demographic and clinical data were observed. The overall prevalence of pain differed neither between the MS and control groups nor between females and males in the MS or control groups. No differences were found between MS patients with pain and those who did not any pain regarding the duration of MS (9.0 (5.0–13.0) vs. 9.5 (5.0–13.0), years, p = 0.854) or age (44.0 (35.0–53.8) vs. 43.5 (28.5–49.8), years, p = 0.311).A total of 240 subjects were included in the study, their demographic and clinical data are presented in p < 0.001), whereas no difference was found in the prevalence of constant pain and the intensity of pain. The percentage of participants who reported analgesic use did not differ between the groups. The comparison of pain characteristics between the MS and control groups is presented in Neuropathic pain and pain of more than 2 years’ duration were more common among MS patients who were experiencing pain compared to that among the control subjects affected by pain (p < 0.05)  .r = 0.573, p < 0.001) and only weakly with HADS-A scores . Higher anxiety and depression levels and lower SF-12 scores were more common among MS patients than among controls regardless of their experienced pain. However, when comparing subjects without pain between the groups, only PSC-12 values were found to be lower in the MS group (data not shown). Therefore, it may be assumed that higher anxiety and depression levels in the MS group are caused by multiple factors, an important one being pain. Data on SF-12 and HADS scores with regard to the presence of pain are summarized in In the MS group, EDSS moderately correlated with HADS-D scores (p = 0.011 and 40.6 (29.9–51.8) vs. 47.3 (37.6–57.5), p = 0.008) and the same was observed when comparing males with pain and MS to the same subset of females. No other gender-associated differences were detected (data not shown).In the MS group, higher values of HADS-D scores and lower values of MSC-12 were found among males than among females (5.0 (4.0–10.0) vs. 4.0 (1.8–7.0), Our study showed a 76.7% prevalence of pain among MS patients that is slightly higher than the prevalence of 62.8% that was reported in a systematic review and meta-analysis of pain in adults with MS ,10,11 anA meta-analysis showed that nearly half of MS patients suffered from headache (42.5%) and that the most common pain syndromes were neuropathic extremity pain 26.6%, back pain 20.0%, and Lhermitte sign 16.6% . AlthougA noteworthy observation to emerge from the data comparison was the detection of lower MSC-12 and HADS-D scores among males with MS and pain in comparison to those for females with MS and pain. A similar observation was reported in another study that showed better self-reported physical and mental health among females with MS .We found that 52.5% of MS patients and 38.3% of controls  used pain medications and these numbers were much lower in comparison to the ones reported in a study that used information from the Swedish Prescribed Drugs Register to analyze the data of more than 3000 MS patients and 4000 controls . The stuFinally, the prevalence of pain in the control group (65.9%) was higher than we had expected. Due to a lack of data on this topic, the comparison of our results to the ones of other studies is complicated; however, a study in the USA that included more than 5000 White, non-Hispanic participants reported that the prevalence of pain in this population was 59.7% , which iFinally, a number of potential shortcomings need to be considered. The most important limitation lies in the fact that this study mainly relied on self-reported data obtained using questionnaires or self-assessment scales. In addition, this was a small-scale single-center study; therefore, the inclusion of participants was limited, and we were unable to gather data on pain and its characteristics in different MS types. This study was not specifically designed to accurately evaluate the prevalence and characteristics of headache; therefore, caution must be taken when interpreting the reported low prevalence of headache.This was the first cross-sectional study to address the question of the prevalence and characteristics of pain in Lithuanian MS patients and to compare their data to controls. This work has revealed that there are no major differences in the prevalence or in the characteristics of pain in Lithuanian MS patients in comparison with the data reported by other authors. The present findings might suggest several courses of action in order to improve the well-being of MS patients. Firstly, physicians should not underestimate the prevalence of pain among those with MS as well as its effect on the mental and physical aspects of quality of life. In addition, given the low rate of pain medication use, it is possible that a significant percentage of MS patients do not receive adequate pain treatment. Pain in MS should be recognized as an important problem that requires the utmost diligence.


The efficacy of stabilization appliance therapy for masticatory muscle pain is debated. Therefore, there are currently no clear usage standards. We analyzed patient factors influencing its efficacy and characterized masticatory muscle pain subtypes to determine appropriate therapy candidates.This case series study recruited patients diagnosed with local myalgia or myofascial pain and used variables related to temporomandibular disorders in the analysis. We used temporary appliance to screen patients for sleep bruxism for 2 weeks. Afterwards, we initiated therapy with stabilization appliances. Efficacy was evaluated via tenderness intensity during muscle palpation and the treatment satisfaction score after 2 months of treatment.We analyzed 62 (91%) patients. Tenderness upon muscle palpation was mitigated in 27 patients. Mitigated tenderness odds ratios were 0.035 for myofascial pain, 0.804 for 15‐item Patient Health Questionnaire scores, and 1.915 for facet length. Thirty‐nine patients expressed satisfaction; satisfaction odds ratios were 0.855 for 9‐item Patient Health Questionnaire scores, 1.606 for facet length, and 4.023 for awake bruxism awareness.Stabilization appliance therapy is most effective for patients with awake bruxism awareness, local myalgia, long facets, and no psychosocial risk factors. Approximately two thirds of patients with TMD seek treatment, and approximately 15% develop chronic TMD associated with an estimated annual cost of $4 billion in the United States. is the second most common musculoskeletal problem, after lower back pain, with a prevalence of approximately 5–12% in the United States (Stabilization appliance therapy (SAT) has long been used to treat masticatory muscle pain, out of 71 patients who presented with orofacial pain at the Tokyo Dental College Suidobashi Hospital between March and December 2016 and who were diagnosed with local myalgia or myofascial pain. We did not recruit patients aged <18 years or those who had moderate or severe systemic disease , loss of posterior support, or temporomandibular joint pain. The exclusion criteria included failure to attend hospital appointments, a deteriorated condition necessitating a treatment switch, and improvements before SAT was started. Written informed consent was obtained from all the participants, and the study protocol was approved by the Ethics Committee of Tokyo Dental College .2.2Items that are associated with TMD in the existing literature, 15‐item Patient Health Questionnaire (PHQ‐15), and 7‐item Generalized Anxiety Disorder (GAD‐7) scale. These assessments screen for depression, somatization, and anxiety, respectively.2.3Temporary screen appliances were used to screen for facets formed by sleeping. Facets formed by sleeping were observed on the surface of the temporary screening appliances, and the length of the facet was measured Figure . Tempora2.4After the screening appliance assessment, SAT was initiated. For each patient, an appliance for nighttime use was made to cover the entire maxillary dentition, and the stabilization appliance's position was adjusted in the same manner as the screening appliance's position. “greatly worsened”, (b) “worsened”, (c) “no change”, (d) “improved”, or (e) “greatly improved”. A score of 1, 2, or 3 was indicated dissatisfaction whereas a score of 4 or 5 signified satisfaction.2.7p < .05 was considered statistically significant.SPSS version 24  was used for statistical analysis, and a 2.7.1U‐test, Student's t test, and χ2 tests. Logistic regression analysis was performed on all items to obtain odds ratios.We compared multiple baseline patient factors in patients with local myalgia and myofascial pain. For the test of normality, the Shapiro–Wilk test was used, and two groups were compared using Mann–Whitney 2.7.22 tests were used to compare the following variables between the two pairs of groups: sex; presence of myofascial pain, anterior guidance, open bite, awareness of awake bruxism, muscle fatigue on waking, torus palatinus or mandibularis, tongue scalloping or lines on the inside of the cheeks, and snoring or apnea; smoking; daily alcohol consumption; and daily caffeine consumption. The Mann–Whitney U‐test was used to compare the pretreatment baseline VAS score, number of tender areas, as well as PHQ‐9, PHQ‐15, and GAD‐7 scores. The Student's t test was used to compare the baseline sleep duration, duration of computer and smartphone use, pain‐free mouth‐opening range, and facet length in the screening appliance's canine region. These variables were further analyzed with logistic regression analysis to identify predictors associated with improvements in VAS scores and those associated with satisfaction.We compared patients who exhibited improvements to those who did not and those who expressed satisfaction to those who did not in terms of multiple baseline patient factors. χ2.7.3Statistical analysis of changes in the number of tender areas, VAS score , and pain‐free mouth opening range of myalgia at the time of initial examination of all participants 1 and 2 months after starting SAT was performed by a Friedman test.2.7.4U‐test was used to compare the number of tender areas 2 months after the start of treatment (between both pairs of groups), VAS score at 2 months (between the satisfied and dissatisfied patients), and treatment satisfaction score at 2 months (between the patients who improved and those who did not). Finally, the Student's t test was used to compare the pain‐free mouth opening range at 2 months (between both pairs of groups).The Mann–Whitney 3First, this study design is uncoordinated and requires a lot of statistical analysis, so there are Type I errors. Also note that the study power is low due to the small sample sizes.p < .001). There was no significant change in the number of tender areas (p = .051) and the pain‐free mouth opening range . Of them, 12 were men (mean age: 50.5 ±17.1 years) and 50 were women (mean age: 47.8 ± 14.7 years). Overall, there were significant improvements in the VAS score (3.1p = 0.029), but there was no difference in other items  but not in the remaining 35 .3.2.1p = .003). Compared with those who did not experience improvements, those who did were significantly less likely to have myofascial pain (p = .001), had significantly lower PHQ‐15 scores (p < .001), and had significantly longer facets (p = .006). Logistic regression analysis of these variables showed that the odds ratios for improvement were 0.035 for myofascial pain, 0.804 for PHQ‐15 scores, and 1.915 for facet length. Sex was not associated with a significant odds ratio  2 months after the start of treatment, the number was significantly lower among the patients who had improved (p = .001). There was also no significant difference in the pain‐free mouth opening range on initial examination (p = .062), but at 2 months, the range was significantly greater among the patients who had improved (p = .019). Satisfaction levels were also significantly higher among the patients who had improved (p = .004).Although there was no significant difference in the number of tender areas on initial examination between patients who improved and those who did not , and dissatisfaction by 23 patients .3.3.1p = .030), had significantly lower PHQ‐9 scores (p = .041), and had significantly longer facets (p < .001). Logistic regression analysis of these factors showed that the odds ratios for satisfaction were 0.855 for PHQ‐9 scores, 1.606 for facet length, and 4.023 for awareness of awake bruxism  2 months after the start of treatment, VAS scores were significantly lower among satisfied patients than among dissatisfied patients (p = .016). There was also no significant difference in the number of tender areas on initial examination (p = .542), but at 2 months, the number among satisfied patients was significantly lower (p = .016). There was no significant difference in the pain‐free mouth opening range at the initial examination (p = .529) or at 2 months (p = .546).Although there was no significant difference in VAS scores on initial examination . Although appliance therapy is regarded as comparatively noninvasive, its efficacy remains unestablished, and it is debatable whether SAT and other treatments that include physical intervention are appropriate. Therefore, at present, the first choice of treatment for TMD is conservative treatment such as self‐massage, and the use of SAT is not recommended. In this study, SAT helped improve myalgia as a result, but we do not recommend SAT as the first choice. However, it may be useful as an auxiliary option for myalgia treatment.Muscle pain treatments can include patient education, cognitive behavioral therapy, physiotherapy, SAT, and pharmacotherapy.. However, ensuring such consistency is extremely difficult. Therefore, this study did not include a control group. Instead, we categorized patients based on whether the treatment ameliorated their symptoms and then analyzed differences in patient factors between those categories. Hence, a limitation of this study is that we did not investigate placebo effects. Furthermore, the patients might have spontaneously healed, so our evaluation of therapeutic efficacy might have included placebo effects and spontaneous healing.Because TMD arises from complex interactions between various factors, the diagnostic criteria for control group patients with TMD should ideally be like those for treatment group patients regarding Diagnostic Criteria for TMDs Axes I and II , the pain‐inducing action of growth factors, and hypersensitivity of the sympathetic nervous system that can increase sensitivity to palpation or tenderness to pressure, sometimes with referred pain.(Maekawa, Clark, & Kuboki, TMD is categorized as a type of functional somatic syndrome, alongside fibromyalgia and somatic symptom disorder,(Henningsen, Zipfel, & Herzog, 4.4Psychosocial factors influence the risk of developing chronic lower back pain and other musculoskeletal disorders,(Hasenbring, Hallner, & Klasen, Depression is thought to be closely association with pain.(Wright et al., The PHQ‐9 is widely used in Japan as a screening tool, and its use has highlighted the association between pain and depression. High PHQ‐9 scores are significantly associated with higher pain intensities in patients with chronic lower back pain,(Vietri, Otsubo, Montgomery, Tsuji, & Harada, Studies on psychosocial stress and TMD have shown that pronounced somatic symptoms represent a strong risk factor for developing TMD.(Fillingim et al., The GAD‐7 is a valuable anxiety screening tool.(Löwe et al., Our results showed that higher PHQ‐9 scores were associated with lower likelihoods of satisfaction with SAT, whereas higher PHQ‐15 scores were associated with lower likelihoods of experiencing improvements, as reflected in VAS scores. In a study of patients with residual pain following knee surgery, Bierke et al.(Bierke, Häner, & Petersen, In TMD management, it is important to evaluate psychosocial risk factors during both the initial examination and the course of treatment and to consider approaches other than conventional treatments such as conservative therapy, SAT, and physiotherapy.5Various masticatory muscle pain subtypes exist. Therefore, detailed examinations of factors, including psychosocial factors, are essential for effectively treating patients with masticatory muscle pain.Our results suggest that patients aware of awake bruxism and with local myalgia who formed long facets on their stabilization appliances would respond better to SAT than those who have myofascial pain or formed short facets. High PHQ‐9 scores indicate a reduced likelihood of satisfaction with SAT, and high PHQ‐15 scores indicate a reduced likelihood of benefiting from this treatment in terms of VAS scores for tenderness during muscle palpation. Therefore, SAT may be most effective for patients aware of awake bruxism and with local myalgia who form long facets on the stabilization appliances and who lack psychosocial risk factors.


Phantom limb pain (PLP) is a type of chronic pain that follows limb amputation, brachial plexus avulsion injury, or spinal cord injury. Treating PLP is a well-known challenge. Currently, virtual reality (VR) interventions are attracting increasing attention because they show promising analgesic effects. However, most previous studies of VR interventions were conducted with a limited number of patients in a single trial. Few studies explored questions such as how multiple VR sessions might affect pain over time, or if a patient's ability to move their phantom limb may affect their PLP. Here we recruited five PLP patients to practice two motor tasks for multiple VR sessions over 6 weeks. In VR, patients “inhabit” a virtual body or avatar, and the movements of their intact limbs are mirrored in the avatar, providing them with the illusion that their limbs respond as if they were both intact and functional. We found that repetitive exposure to our VR intervention led to reduced pain and improvements in anxiety, depression, and a sense of embodiment of the virtual body. Importantly, we also found that their ability to move their phantom limbs improved as quantified by shortened motor imagery time with the impaired limb. Although the limited sample size prevents us from performing a correlational analysis, our findings suggest that providing PLP patients with sensorimotor experience for the impaired limb in VR appears to offer long-term benefits for patients and that these benefits may be related to changes in their control of the phantom limbs' movement. Phantom limb pain (PLP) is a type of chronic pain caused by limb amputation . Besidesper se  from China-Japan Friendship Hospital in Beijing. All suffered from medium to severe levels of daily pain, and three of five have been taking the pain and/or antianxiety medicine. Detailed medical and demographic information is listed in The immersive room-scale VR system and HMD were from HTC VIVE  with 1,0We assessed the changes in pain ratings both before and after the VR intervention. Two pain ratings were used (1) Short-Form McGill Pain Questionnaire (SF-MPQ), which is the pain rating index (ratings from 0 to 75) formed by the summed contribution of 15 characteristics of pain ; and (2)Each session lasted approximately 1 h with the following steps :The patient filled out the questionnaires for self-reported anxiety and depression ratings before session 1, and SoO and SoA ratings after session 1.The researcher conducted semistructured interviews to collect the patients' subjective feedback before each session. The questions regarded (a) pain qualities and frequencies, (b) sleep quality, (c) medicine intake, (d) emotional changes, and (e) any other thoughts.The patient filled out the two pretest pain questionnaires before each session.The patient wore a VR HMD and held a controller in their intact hand, performing two motor tasks for 30 min .The patient carried out the motor imagery and motor execution tasks, once before the first session and once after the last session. Before the former, the researchers detailed the task instructions before a practice session when patients performed the two VR motor tasks by execution and by imagery, three times each. The ball-pushing task required the participant to push a ball off the table with extension of both virtual limbs whose motion was driven by the measured motion of the intact limb only. The ball-shoot task is to extend both limbs to shoot a basketball toward a basket. Again, the motion of two limbs was driven by the intact limb only; the ball release was initiated by clicking the trigger button on the controller. The order of these practice runs  was pseudorandomized across patients, and they performed each for three times per session. In the subsequent former test, patients were asked to visually imagine performing the two VR tasks with either limb (not both limbs); each task and each limb was repeated three times. They were instructed not to perform motor imagery unless they were told to. Patients then executed each task with the intact hand for three times. For each trial, the patient clicked the trigger button of the controller once before the trial, and once after the trial to register the time needed for imagery and execution.The patient filled out the posttest VAS ratings after each session.The patient filled out the questionnaires for self-reported anxiety and depression ratings, and SoO and SoA ratings immediately after the last session.Z = −2.02, p = 0.043, r = 0.9). Notably, all patients showed continuous pain reduction over consecutive sessions. Overall, patients reported an average improvement of 56.96% (SD = 17.49%) on the SF-MPQ ratings when comparing the last session, they took part in with their first session. Specifically, 56% improvement (SD = 18.08%) was on the pain sensation categories  and 58.33% (SD = 30.5%) on the emotional categories . Notably, all patients showed more than 50% improvement , although their initial pain ratings differed substantially  and “somatosensory-related pain characteristics” , as a previous study found that VR mirror-movement therapy specifically improved the kinesthesia-related pain characteristics . HoweverZ = −2.02, p = 0.043, r = 0.9). Comparing VAS ratings across days, we found a marginally significant difference in pretest ratings between the first session and the third session ; however, the posttest ratings did not show a significant across-session difference , possibly because the analgesic effect in each session masked the across-session differences. The average improvement of the VAS rating was 19.04% (SD = 13.47%). We found that each session induced an average improvement of 21.23% (SD = 15.95%) when comparing the pre-test VAS ratings with the posttest ones. All five participants showed this one-session improvement. Given the small sample size in this study, we would like to state the statistics should be viewed with caution.The VAS ratings showed a similar but less drastic analgesic effect than the SF-MPQ ratings . The aveThe performance of motor imagery and execution was quantified by their movement time , 4. FirsThe rating of SoO and SoA for the avatar in the VR increased in our experiment . The ratThe patients' anxiety and depression levels were measured using HADS, once before the first session, and once after the last session . We missAll patients reported one or a few positive changes after the intervention. Here, we report the qualitative results briefly. P01 said the VR intervention had provided him with an analgesic effect ranging from 2 h or longer until he went to bed at night. However, his anxiety from over 10 years of suffering hardly changed. P02 did not report a substantial change in pain before and after each intervention, but he did report a substantial decrease in pain ratings across the entire study. Furthermore, he reported multiple pain sensations in SF-MPQ initially, and only one at the study's conclusion. P03, before the study, reported over 30 times of “unbearable bursts of pain every day,” which he rated as 9 or 10 in VAS and lasted for 1 to 5 min. After the study, P03 reported that the intensity of his pain bursts was “much more endurable now” and that they lasted half the time. Notably, P03's quality of sleep steadily improved. Before participation, he woke up 8–10 times because of the pain bursts; at the conclusion of the study, he only woke up two to three times per night. P05's reported similar improvement in sleep: before the study, he reported, “I have problems falling asleep and I need to take pills. But now I don't need to.” Surprisingly, even though we did not ask, three out of five patients mentioned that they dreamt that their impaired limb moved again, the same way it had before their injury. According to P05, “I had a dream yesterday, and I saw my right hand and arm moving! It felt so good and so vivid that I can still remember.” Thus, these semistructured interviews showed that all five patients' subjective experiences are consistent with the quantitative measures, including pain ratings and motor imagery time.Our brief report with five PLP patients reveals that a long-term VR-MT intervention produced substantial analgesia, indexed by SF-MQP and VAS pain ratings, along with improved phantom limb movement, quantified by reduced motor imagery time. Short-Form MQP and VAS ratings showed different percentages of improvement, given that they measure different aspects of pain perception with different levels of responsiveness , 36. We These findings suggest that VR-MT interventions hold promise as effective analgesia for patients who suffer PLP, particularly considering that four out of five participants suffered severe PLP for more than 10 years, and were first treated with at least one of the traditional pain management methods. Therefore, it is unlikely that carryover effects from previous therapies can explain our findings. For the same reason, pain relief owing to natural regression to the mean effects is unlikely to explain the observed large effect. Furthermore, patients who were taking medication had already been on it for over 2 years without an increase in dosage during the study; this makes medications an unlikely explanation for our results.In our study, five patients underwent the VR intervention for 4–6 weeks, ranging from 3 to 10 sessions . PreviouWhile the potential of using VR for relieving PLP has been demonstrated, why and how it works remain unclear. Some researchers believe that having a sense of ownership over a virtual body in VR might alleviate pain for healthy subjects and pain patients , 44. OthWith the growing evidence that the level of the phantom limb's movement may be correlated with a cortical or subcortical reorganization, others have also suggested that improved phantom limb movement may be associated with pain reduction . HoweverThe first limitation of this study is the small sample size which prevents us from establishing the correlation between pain reduction and accompanied changes in the phantom limb movement and embodiment. In future studies, we plan to conduct a longitudinal controlled trial with more samples and methodological improvements. For example, a motor imagery test can be performed measuring electromyography in residual muscles. Sense of agency and SoO can be potentially quantified by more objective approaches, such as intentional binding. We could also compare VR interventions without or without a virtual body. The VR experience can be complemented with haptic feedback to enhance embodiment . ImportaAll datasets generated for this study are included in the article/The studies involving human participants were reviewed and approved by the Ethical Review Board of Peking University. The patients/participants provided their written informed consent to participate in this study.Written informed consent was obtained from the participants for the publication of any potentially identifiable images or data included in this article.XT and KW designed the study and the VR environment. XT and XW conducted this research study. XT, KW, YC, DG, XW, and BF wrote and revised the paper. XW and BF recruited participants. OW gave suggestions to the VR environment design and revised the paper. 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.


To establish whether early use of magnetic resonance imaging (MRI) or computed tomography (CT) influences treatment and outcome of patients with low back pain.This study will be implemented from March 2021 to March 2022 at Huzhou Traditional Chinese Medicine Hospital Affiliated to Zhejiang Chinese Medical University. The experiment was granted through the Research Ethics Committee of Huzhou Traditional Chinese Medicine Hospital Affiliated to Zhejiang Chinese Medical University (R609320987). Patients who have symptomatic lumbar spine disorders at presentation are eligible for the trial if there is clinical uncertainty about the need for imaging (MRI or CT). Patients are excluded who required immediate referral for imaging , who have undergone MR imaging or CT of the spine within 1 year, who do not need imaging, and who have pain of a nonspinal origin. The primary outcome measure is the Aberdeen Low Back Pain (ALBP) score. Other principal outcome measure is the Short Form 36.Table 1 will show the quality of life outcome measures between groups.This study may guide the policy makers to develop an evidence-based protocol to assess the effect of early use of MRI or CT in the treatment of patients with low back pain. Although low back pain is highly prevalent and invades all walks of life, the consequences are especially grave for the elderly.Spinal disorders, especially low back pain, affect many people and have a negative impact on work capacity and on the overall wellbeing of an individual. Low back pain is shown to be a major problem throughout the world, with the highest prevalence among women and those aged 40 to 80 years. Overall, the annual prevalence of low back pain has been reported to range from 15% to 45% and the prevalence of severe low back pain continues to increase with age. Advanced imaging, computed tomography (CT), or magnetic resonance imaging (MRI) are helpful if radiographs are not explanatory of unremitting lower back pain or there is substantial clinical suspicion for an underlying systemic disease.,10 MRI without contrast is generally considered the best initial test for most patients with low back pain who require advanced imaging. In patients who require advanced imaging but cannot have an MRI, a CT scan is usually the next step. It is unclear which of the diagnostic imaging pathways is most effective and cost-effective and how the imaging impacts on patient treatment. The objective of this randomized controlled protocol is to establish whether early use of MRI or CT influences treatment and outcome of patients with low back pain.A global review of the prevalence of low back pain in the adult general population was published in 2012.2This study will be implemented from March 2021 to March 2022 at Huzhou Traditional Chinese Medicine Hospital Affiliated to Zhejiang Chinese Medical University. The experiment was granted through the Research Ethics Committee of Huzhou Traditional Chinese Medicine Hospital Affiliated to Zhejiang Chinese Medical University (R609320987) and recorded in research registry (researchregistry6420).2.1Patients who have symptomatic lumbar spine disorders at presentation are eligible for the trial if there is clinical uncertainty about the need for imaging (MRI or CT). Patients are excluded who required immediate referral for imaging , who have undergone MR imaging or CT of the spine within 1 year, who do not need imaging, and who have pain of a nonspinal origin.2.2After we obtain informed consent, research nurses collect baseline clinical and demographic details, and participants complete health status questionnaires prior to random assignment to groups. At 12 and 24 months, health status measures and information about primary care consultation, purchase of prescription and nonprescription medicines, and discontinuation or interruption of usual activities because of low back pain are collected with postal self-completion questionnaires. Telephone calls and reminder letters are used to increase the return of questionnaires.2.3Sequence of random numbers is generated by a computer. Sequentially numbered sealed opaque envelopes are used for the concealment of random numbers. All the patients taking part in our experiment are randomly divided to the early imaging group (in which MRI or CT is performed as soon as was practicable) or the delayed selective imaging group .2.4 Responses to the 19-item questionnaire are summed and converted to a percentage score (scores range from 0 for least disabled to 100 for most disabled). Other principal outcome measure is the Short Form 36, a generic instrument that is widely used and has been shown to be a reliable and valid instrument for the assessment of functional status.The primary outcome measure is the Aberdeen Low Back Pain (ALBP) score. This condition-specific questionnaire allows assessment of low back pain across several dimensions, including pain, physical impairment, and functional disability.2.5t tests and χ2-tests are respectively utilized to analyze the categorical variable and continuous variable. When P is less than .05, the efficacy is viewed to be statistically significant.The analysis of all the data are conducted with the software of IBM SPSS Statistics for Windows, version 20 . The data obtained are represented through the proper features, for example, standard deviation, and mean, median as well as percentage. And independent 3Table 4,13 It has an enormous impact on individuals, healthcare systems, and national economies, and treatment approaches have important consequences for patients, clinicians, and society.,15 Although most episodes are self-limiting, for a minority of patients referred to a specialist, the place of cross-sectional imaging techniques such as MRI or CT in the treatment of low back pain is controversial.Back pain affects most adults, is a leading cause of activity limitation and work disability worldwide, and is among the most common reasons for seeking healthcare. There are demands for more rigorous scientific evaluation of both the clinical effectiveness and cost-effectiveness of new health care technologies such as MRI or CT prior to their widespread diffusion and use.Decisions about the use of sophisticated imaging will depend to an important extent on judgments about the value of the observed differences in outcome and whether they are worth the extra costs of early imaging. The use of MRI does not appear to affect treatment overall, and the small observed improvement in outcome is of questionable clinical importance. Although some researchers may argue that any improvement is worthwhile, given that the other costs of treatment do not appear to be increased, others may say that the cost of providing a small improvement in patients’ overall well-being is not justifiable, especially when there are competing demands for MRI resources.5This study may guide the policy makers to develop an evidence-based protocol to assess the effect of early use of MRI or CT in the treatment of patients with low back pain.Weiqiang Shen designs the protocol. Xuming Pan reviews the protocol and performs the data collection. Jianjian Zuo finishes the manuscript. All of the authors approved the submission.Conceptualization: Jianjian Zuo.Formal analysis: Xuming Pan.Funding acquisition: Weiqiang Shen.Investigation: Xuming Pan.Methodology: Xuming Pan.Writing – original draft: Jianjian Zuo.


Chronic, non-surgical, non-specific anterior knee pain is a common source of functionally limiting chronic ailment, especially in a young athletic and active-duty military population. The infrapatellar branch of the saphenous is becoming a common therapeutic target for the diagnosis and treatment of anterior knee pain. It is a nerve commonly injured during knee surgeries and trauma, resulting in neuroma formation and chronic neuropathic pain states, and it can also transmit nociceptive input from patients with non-surgical anterior knee pain of multiple etiologies. Several methods have been employed to treat this condition. After the diagnosis of infrapatellar saphenous neuralgia, the nerve is safely ablated using radiofrequency ablation, neurolytic solutions, and, most recently, cryoablation using the handheld iovera® cryoablation system . Cryoablation is an attractive technique because it is minimally invasive, not permanent, and well tolerated by the patient with only local anesthesia. We have previously described a technique using a non-invasive peripheral nerve stimulator to identify and treat the exact location of the nerve more precisely, thereby optimizing treatment success and procedural simplicity. This case series illustrates our initial use and success with this technique. Further follow-up and randomized sham-controlled trials are also planned. Anterior knee pain is a common clinical condition with a prevalence ranging from 11 to 22.7% in the general population and 28.9% among adolescents -5. AnterDiagnostic workup for anterior knee pain can be challenging given the lack of consensus regarding the specific pathogenesis  and the A structured clinical examination matched with the patients’ symptoms may assist in identifying structural and biomechanical faults in the lower extremity. However, reliance on common clinical tests performed during the objective examination may only be helpful in ruling out other similar conditions . It may Multimodal physical therapy has been shown to be effective in the management of anterior knee pain . SeveralMany techniques have been suggested and trialed for patients for whom rest, conservative care, physical therapy, and rehabilitative efforts have failed. These include oral medications, bracing, acupuncture, transcutaneous electrical nerve stimulation (TENS) therapy, massage, corticosteroid injections, viscous-supplementation, prolotherapy, platelet-rich plasma therapy, and nerve ablation procedures -18. TherAfter discussing the procedure with the patient and obtaining informed consent, a line is drawn 5 cm medial from the inferior pole of the patella and tibial tubercle. Next, the peripheral nerve stimulator with a transcutaneous bipolar probe is placed on the skin with a stimulus amplitude dial set approximately at 2, and then the 50-Hz tetanus setting is used to stimulate the nerve. The patient is instructed to indicate when they feel a pinch or tingling sensation. The device is used to scan up and down a vertical line approximately 5 cm from the patella and tibial tuberosity. If the patient does not feel the stimulation at this setting, the intensity is gradually increased in approximately 0.5 increments until the patient detects a sensation at one of the terminals. We have found that for our patient population, the stimulation threshold has been at approximately 3-4 on the dial. After the perception of the stimulus, we make a slow and deliberate scan Figure  of the aTable Anterior knee pain is among the most common knee conditions encountered by primary care physicians, orthopedic surgeons, and sports medicine specialists. This case series served primarily as a feasibility study to demonstrate the relative simplicity and effectiveness of a novel IPBSN identification and treatment technique and investigate the therapeutic benefit of applying cryoablative treatment at this location in patients suffering from chronic, non-specific anterior knee pain. Given the significant anatomic variability of the IPBSN course , the autTwenty-three patients  who had a positive response to diagnostic IPBSN block received cryoablative treatment in this case series. A response was considered positive when there was an equal to or greater than 50% drop in Defense and Veterans Pain Rating Scale (DVPRS) pain score either at rest or during the patient’s painful activity. The patients’ age ranged from 24 to 67 with a mean age of 42.5 years. Thirteen patients had a diagnosis of chondromalacia patellae and six patients had a diagnosis of patellofemoral pain syndrome (PFPS). One patient was diagnosed with both chondromalacia patellae and PFPS. Two patients had normal-appearing imaging studies and their condition was designated as “other” non-specific anterior knee pain.At the time of this case series submission, four patients had returned for repeat cryoablation of the same IPBSN after regeneration of the target nerve and return of their pain. Their duration of relief (>50% DVPRS drop from baseline) ranged from six to nine months. The same procedure was repeated for these patients with immediate post-procedure pain relief. The remaining 19 patients have not yet returned for follow-up or repeat treatment after one to nine months of initial treatment, possibly indicating that the pain has not returned to pre-treatment levels.This case series has some limitations, including those that are inherent to case series in general, such as the lack of control subjects making case series prone to selection bias. In addition, the lack of follow-up makes it difficult to accurately determine the actual procedure success and delayed complication rate. Additionally, this case series lacked uniformed pre-defined follow-up duration after treatment because our patients have generally tended to appear for follow-up or repeat treatment only when they feel their symptoms have returned to a “significant” level. Future studies should have pre-determined interval follow-ups to quantify the loss to follow-up, which can be an important factor in assessing study quality. In addition, pre-set follow-ups may identify cases where patients no longer experience satisfactory pain relief but still failed to return for re-evaluation or repeat treatment for whatever reason.This case series had one sole outcome measure: change in DVPRS numerical score. Future study endpoints should include functional measures such as the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) as improvement in function in conjunction with pain relief has been widely accepted to yield a more meaningful assessment of the quality of life than pain scores alone.Moreover, future studies will ideally be randomized, double-blind, and sham-controlled in design. These studies could include the following cohorts: 1. cryoablation utilizing the novel nerve identification technique; 2. cryoablation using the manufacturer’s (iovera®) recommended treatment location; 3. sham ablation utilizing the novel nerve identification technique; and 4. sham ablation using the iovera®-recommended treatment location.While acknowledging its limitations, we believe this case series demonstrates positive outcomes of a novel diagnostic and therapeutic procedure as part of a high-impact treatment in patients who had an inadequate response to rehabilitation and conservative treatment and limited alternative options for pain relief and functional improvement. We hope that this case series and procedure report will encourage physicians/researchers to conduct more advanced studies, which would lead to a widespread acceptance of this quick, seemingly effective, and well-tolerated technique.


Routine physiotherapy has been advocated was an effective treatment for internal shoulder impingement syndrome. However, there is lack of best exercise treatment and lots of studies are under consideration. The objective of the study was to compare the effects of Neuromobilization and routine physiotherapy on pain in patients having shoulder internal impingement syndrome.th and 11th week.This is a single blinded randomized control clinical trial that was conducted at Social Security Hospital Gujranwala in which 80 patients with SIS were participated. The duration of study was from September 2016 to March 2018. Patients were recruited after giving an informed consent and were randomly assigned to either control or experimental group which was treated with routine physiotherapy and routine physiotherapy plus neuromobilization respectively; pain was assessed by Numeric Rating Scale at base line, 5th week had lower mean pain score 2.15(1.66-2.64) vs 4.90(4.41-5.40); between group difference, 1.82; 95% (CI), -2.38 to -1.25; P < 0.001 and Partial Ŋ2=0.33. These results show that pain score is much improved in experimental group.The experimental group compared with control group at 11Neuromobilization along with physical therapy is more effective as compared to physiotherapy alone. The internal shoulder impingement syndrome (SIS) consists of the rotator cuff tendonitis and bursitis of the shoulder.2The internal SIS comprises of three stages, stage I impingement is defined by edema and hemorrhage of the subacromial bursa and rotator cuff, it is found in patients who are less than 25 years old. Stage II impingement represents irreversible changes, such as fibrosis and tendinopathy of the rotator cuff. It is mostly found in patients who are up to 25 to 40 years old. Stage III impingement is marked by more-chronic changes, such as partial or complete tears of the rotator cuff, and usually it is seen among the patients who are more than 40 years old.3The concept of neuromobilization (NM) includes connection between mechanics and physiology of the nervous system in which interactions occur both ways and can be beneficial intensely for shoulder pain. Mechanical management may therefore be used to augment physiology in the nervous system. NM sequencing is the performance of set of particular component body movements so as to produce specific mechanical events in the nervous system, according to that sequence of component movements.5Mechanical and vascular theories are regularly used for the treatment of tendon pain. The neural component is over looked due to poor outcomes among patients with tendinopathy. Matocha MA et al. highlighted neural involvement in patients with tendon pain and discussed the role of NM for tendon pain.6The neural theory includes number of elements that may lead to tendon pathology, increased stress and tension on nerve will result in decreased blood flow to the specific nerve which will affect blood flow to tendon.Clinically analyzed eighty patients of internal SIS who visited physiotherapy department were enrolled for this specific analysis. The duration of study was from September 2016 to Match 2018. The study was described to all patients and informed consent was taken from them. This very consent process and Form was approved by Institutional Review Board, University of Lahore  before the initiation of random selection. Those participants were recruited who attended physiotherapy department, Social Security Hospital Gujranwala.IRCT20190121042445N1. It was registered retrospectively.The design of study was single blinded randomized controlled clinical trial. Sample size calculation was derived from Yamany AA et al.’s study.101-α/2 is type 1 error=1.96, Zβ=0.84, d=µ2-µ1=10.7. Based on this a total sample size of around 80 was calculated to be an adequate mean to reach the conclusion. Considering a loss of 20% follow-up, at least 80% patients followed the treatment.Where SD= Standard deviation=14.08, Z Numeric Rating Scale (NRS) was used to assess the intensity of pain which is valid and reliable measure of pain intensity. A continuous scale was used to ask the patients to think about their shoulder pain during the activity and to rate it by marking on a 10-mm line; it was anchored with “no pain” and the “worst pain you have ever felt”. This is a well-accepted method of evaluating the pain intensity levels.122,The routine Physiotherapy consisted of pulsed Short Wave Diathermy with frequency 27.12 MHZ, Ultrasonic Therapy with frequency 1.0 MHZ and intensity 1.45w/cmNM was applied using Butler’s recommendations.All participants had gone through a detailed systemic physical examination, that includes neurologic and musculoskeletal evaluations and the patients excluded from the above study who had gone through the shoulder surgery, shoulder injury, cervical radioculopathy and other systemic diseases. The patients who are diagnosed of having positive upper limb tension testth week) and after 1st follow up (11th week).An independent assessor, who specialized in musculoskeletal injuries with more than five year experience of dealing patients with shoulder injury, was masked to the group allocation of the patients for the treatment. The patients were evaluated at baseline, after last treatment . The confidence interval of 95% was used and p value ≤ 0.05 was considered as significant.The data were analyzed using SPSS version 22.0 software. Qualitative data were presented in frequencies and percentages. For quantitative data, mean and standard deviation (S.D) were calculated. Repeated measure ANOVA was applied among both the groups to calculate the average pain score at different times  was 6.95±1.176, and 2.15±1.54 at base line and 11th week respectively. Above mentioned results show the clear difference in average shoulder pain between two groups and shoulder pain of experimental group was more improved as compared to control group at different stages.The results of pain are reported in . For the2=0.33 and p-value<0.001at 95% confidence interval in pain score at different time points  between control and experimental group as shown in  indirectly associated with manual therapy indicates the spinal cord mediated effect of the manual therapy. Hypoalgesia following NM may also occur due to its effect mediated through spinal cord.26Recognizing the close relationship between physical capacities and life style, it is likely that implementation of effective NM treatment as standard part of the treatment for SIS patients would decrease shoulder pain. This study shows that NM not only is feasible as part of the treatment, but also has a large effect size and is time efficient.SIS patients suffer from many challenges, it is important to recognize that their shoulder pain constitutes an important part of overall health and daily tasks. Since SIS are known to be important key factor for daily life activities in term of pain. Importantly, this study, as well as NM regimes is feasible and safe to carry out within this patient group.Su Y et al. highlights that neural tissue management is not better to other forms of treatment in decreasing pain.27The patients included were collected from single hospital. They may have specific demographic and clinical features which might limit the generalization of the outcomes.According to published data summaries of research focusing on management of shoulder pain, it looks like that therapeutic exercise is not sufficient to treat shoulder internal impingement syndrome and it is compulsory to combine with other remedies to get the best results.29The outcomes of current study might be implicated that each of this outcome measure represented only one particular feature of clinical entity. To effectively treat a patient with internal SIS, the interventions require addressing the multiple aspects of the presenting clinical issues.NM technique is more effective and safe adjunct than routine physiotherapy in terms of greater reduction of pain in SIS patients.MA: Collected data, analysis and its interpretation.HK: Conception & study design.PAG: Revising it critically and final approval of manuscript.AA: Drafting and data interpretation.All authors have read and approved the manuscript.The corresponding author Dr. Muhammad Akhtar is responsible and accountable for the accuracy or integrity of the work.


The infection of severe acute respiratory syndrome coronavirus (SARS-CoV) 2 has raised rapidly from the outbreak in Wuhan within the Chinese Hubei province all over the world resulting in a pandemic emergency, which has remarkably affected the Italian population since February 21, 2020 . Among tADRD affect some 50 million people worldwide  and 900–In this field, pain is considered one of the most important causes of BPSD . In partThe 72% of patients older than 85 years suffer from pain , 27, andInterestingly, previous investigations have described the use of telemedicine as a useful tool to follow or treat clinical populations in catastrophic situations or in public health emergencies . ThroughThe SARS-CoV 2 has changed the management of chronic conditions often occurring in the main target of COVID-19 represented by the aged population. One of the most common comorbidities in these patients is dementia, often accompanied by chronic pain. The assessment and management of pain in demented patients is necessary during COVID-19 pandemic emergency, and the use of telemedicine can allow a safe handling reducing the access to hospitals and clinics to contain contagion. We suggest pain management to improve the quality of life of patients and to reduce agitation : accuratDS, MC, GB, and PT have conceived the work. All authors listed have made a substantial, direct and intellectual contribution to the work, and approved it for publication.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.