To characterize the impact of comorbidity on survival outcomes for patients with nasopharyngeal carcinoma (NPC) post radiotherapy (RT).A total of 4095 patients with NPC treated by RT or RT plus chemotherapy (CT) in the period from 2007 to 2011 were included through Taiwan’s National Health Insurance Research Database. Information on comorbidity present prior to the NPC diagnosis was obtained and adapted to the Charlson Comorbidity Index (CCI), Age-Adjusted Charlson Comorbidity Index (ACCI) and a revised head and neck comorbidity index (HN-CCI). The prevalence of comorbidity and the influence on survival were calculated and analyzed.Most of the patients (75%) were male (age 51±13 years) and 2470 of them (60%) had at least one comorbid condition. The most common comorbid condition was diabetes mellitus. According to these three different comorbidity index , higher scores were associated with worse overall survival (P< 0.001). The Receiver Operating Characteristic (ROC) curve was used to assess the discriminating ability of CCI, AACI and HN-CCI scores and it demonstrated the predictive ability for mortality with the ACCI  was superior to that of the CCI  and HN-CCI .Comorbidities greatly inﬂuenced the clinical presentations, therapeutic interventions, and outcomes of patients with NPC post RT. Higher comorbidity index scores accurately was associated with worse survival. The ACCI seems to be a more appropriate prognostic indicator and should be considered in further clinical studies. Nasopharyngeal carcinoma (NPC) is rare worldwide, but occurs with high prevalence in Chinese populations . Taiwan Several instruments have been developed to assess, quantity and grade the degree of comorbid burdens using ordinal scales. One of the most widely applied is the Charlson Comorbidity Index (CCI), which has been extensively used to evaluate the impact of comorbidity in a variety of cancers and non-cancer conditions. The CCI was developed in 1987 and is a prognostic taxonomy that was initially developed to account for the inﬂuence of a patients’ adverse medical conditions in longitudinal studies –7 and haThus, the present study, which was based on nationwide databases, focused on estimating the incidence of comorbidity and its impact on management in a cohort of patients with NPC consecutively planned and treated within RT or RT plus CT in Taiwan. A secondary objective was to compare these three different indices via the CCI, AACI and HN-CCI for predicting the outcomes in Asian NPC patientsThis study used the Taiwan National Health Institute Research database (NHIRD), which was released by the Taiwan National Health Research Institute (NHRI) and available to all researchers in Taiwan. Taiwan initiated its National Health Insurance (NHI) program in March 1995. This system enrolls up to 99% of the Taiwanese population and contracts with 97% of all medical providers ,14. The All patients with NPC  who received curative RT or RT plus CT as initial treatment between the years 2007 and 2011 were identified. Initially, we inspected 6076 NPC patients who were treated with radiotherapy from Taiwan’s NHI research database. Taiwan’s NHI program covered 99% of the population after 2003 which charts reviews and patients interviews used to verify the accuracy of diagnosis and treatment coding. We excluded patients who were treated for second course of radiotherapy and who received systemic or induction chemotherapy as the initial treatment except those who received chemotherapy within 14 days prior to radiotherapy. Finally, after excluding the patients with missing data, a total of 4095 patients during this period were included in this study . These NInformation on pre-existing comorbidity present before to the NPC diagnosis half a year was obtained and we utilized the comorbidity index developed by Charlson et al. to quantify baseline comorbidities available from the trial database ,11. ThisP value < 0.05 was regardedas statistically significant. Receiver Operating Characteristic (ROC) curves was generated to assess the accuracy and the predictive ability of each index for survival. It plots the false rate against the sensitivity to determine its overall accuracy in assessing the outcome. The area under the ROC curves for each index was compared with 95% confidence interval (CI). All data were analyzed using Statistical Package for Social Sciences (SPSS) version 15.Patients were regularly followed up and assessed after RT until death or their latest follow-up appointment. Patients alive on the last day of follow-up were censored. The prevalence of the different comorbid conditions was calculated and described. Overall survival was estimated using the Kaplan—Meier method and the difference between groups were analyzed using log-rank test. The Cox proportional hazards regression model was used for multivariate analysis. Differences between variables with categorical data were examined using the chi-square test. A From 2007 to 2011, a total of 4095 patients diagnosed NPC receiving RT or RT plus CT were included in this analysis. These patients comprised 3080 men and 1015 women with a mean age of 51±13 years. Most patients  received a combination of RT with systemic chemotherapy. The characteristics of this study population are summarized in Table1. The distribution of comorbidity for these patients based on the index is shown in p <0.001).A Charlson comorbidity score was calculated for each patient to classify comorbidity and grouped as having either no comorbidity (CCI = 0), moderate comorbidity (CCI = 1–5) or severe comorbidity (CCI ≥ 6). In total, no comorbidity was found in 39.7%, moderate comorbidity in 19.6% and severe comorbidity in 40.7% of these patients . The inﬂP < 0.001). The 5-year OS was 65% for HN-CCI = 0 and 24% for HN-CCI of more than 1 point. Thus, by using the HN-CCI to classify comorbidity, we were able to stratify patients to different prognostic groups and those patients with comorbidities had poor outcomes.Based on the simple and main six medical conditions, the head and neck comorbidity index score (HN-CCI) were also calculated  by six cThe ROC curve was used to assess the discriminating ability of CCI, ACCI and HN-CCI scores. The predictive ability for mortality of ACCI is superior to that of CCI and HN-CCI . The areThis population-based study demonstrated the importance of comorbidity in Asian NPC patients post radiotherapy. Our study on 4095 patients revealed that non-cancer-associated morbidity occurred in 2470 patients (60.3%) and was different from the comorbidity associated with smoking and alcohol abuse such as cardiovascular and hepatic diseases . Based oComorbidity can impact patient survival, which can lead to the development of non-cancer-associated competing mortality . HoweverP<0.0001). Prevalence rates of comorbidity were 64%, 27%, 7%, and 2% for CCI of 0, 1, 2, and ≥3, respectively. After adjustment for either stage alone or stage and smoking and alcohol history, CCI was prognostic . The prevalence and severity rates of comorbidity observed in our patients were higher than the previous study. Most patients (60%) had comorbidities and most conditions were more severe (40% with CCI≥6). Cardiovascular and pulmonary diseases are the most common comorbidities occurring in Caucasians. However, the most frequent comorbid condition in the current study was diabetes mellitus, followed by peptic ulcer disease and pulmonary disease.Comorbidity indices are commonly used as synopsis for research and clinical purposes. The validity of a comorbidity index is based upon the assumption that increasing comorbidity will be associated with worse health outcomes. Assessment and measurement of comorbidity in head and neck squamous cell cancer patients have been actively investigated in the past and different methods/indices have been applied –20. The Some reports have proved the major role of comorbidity in the treatment outcomes of patients with NPC. A small study (n = 59) by Ramakrishnan et al.  reportedThe HN-CCI reported by Bøje et al.  has seveOur study has a few noteworthy limitations. First, we could not assess the relationship of comorbidity index to NPC stage because the staging information was not available from the database. Second, instead of cancer-specific survival rates, overall survival rate was used, because it was not possible to determine cause-specific mortality based on the registry data. A previous study by Bøje et al. also showed cancer specific death CCI was not influenced by comorbidity with 5-year disease specific survival. Third, the diagnosis of NPC and record of comorbid conditions are dependent factors on ICD codes. Different coding quality among each level of hospitals could result in bias. However, the NHI program in Taiwan reviewed charts to verify the accuracy of diagnosis and treatment coding. Given the robustness of the evidence and statistical analysis in this study, these limitations were unlikely to compromise our results.Our data demonstrate the significant survival impact of age and comorbidity on Asian patients with cancer of nasopharynx treated by RT or RT plus CT. The assessment of comorbidity is of great importance, and should optimize to treat patient’s health before RT. The CCI, ACCI and HN-CCI correlate well with survival and could be used for therapeutic decision-making. However, our analysis suggests the ACCI may be more useful and meaningful for further clinical studies.


Short-term vasodilatation in the pain area after dry needling (DN) of active trigger points (TrPs) was recorded in several cases of sciatica. Moreover, the presence of TrPs in sciatica patients secondary to primary lesion was suggested. Still, it is not known how often they occur and if every TrPs can provoke vasomotor reactions.The purpose of this study was to evaluate the prevalence of active TrPs among subacute sciatica patients and the response to DN under infrared thermovision (IRT) camera control.Fifty consecutive Caucasian patients (mean age 41.2 ± 9.1y) with subacute sciatica were diagnosed towards gluteus minimus TrPs co-existence. Based on TrPs confirmation, patients were divided into two groups: TrPs-positive and TrPs-negative, than DN under IRT control was performed. Skin temperature changes and the percentage size of vasomotor reactions in the pain area were evaluated if present.The prevalence of active TrPs was 32.0%. Every TrPs-positive presented vasodilatation dependent on TrPs co-diagnosis (r = 0.72 p < 0.000) and pain recognition during DN (r = 0.4 p < 0.05). The size of vasodilatation in TrPs-positive subjects was: post-DN 12.3 ± 4.0% and post-observation 22.1 ± 6.1% (both p = 0.000) versus TrPs-negative: post-DN 0.4 ± 0.3% and post-observation 0.4 ± 0.2%. A significant temperature increase in the thigh and calf was confirmed for TrPs-positive subjects only (both p < 0.05). Post-DN and post-observation temperatures were as follows: average  and maximum .The presence of active TrPs within the gluteus minimus muscle among subacute sciatica subjects was confirmed. Every TrPs-positive sciatica patient presented DN related vasodilatation in the area of referred pain. The presence of vasodilatation suggests the involvement of sympathetic nerve activity in myofascial pain pathomechanism. Although the clinical meaning of TrPs in subacute sciatica patients is possible, further studies on a bigger group of patients are still required. Trial registration: Australian New Zealand Clinical Trials Registry ACTRN12614001060639. Registered 3 October 2014. A growing interest in myofascial pain syndrome caused by trigger points is currently observed among researchers. Myofascial pain syndrome is a type of muscle pain caused by trigger points, which are responsible for sensory, motor and autonomic symptoms. Trigger points (TrPs) defined as hyperirritable spots in the taut bands of muscle fibers can be classified as either active or latent. While an active TrP is characterized by spontaneous pain or pain in response to movement, stretch or compression, a latent TrPs is a sensitive spot with pain or discomfort in response to compression only. Additionally, appropriate stimulation of TrPs can elicit spinal cord reflex called “twitch response”, which is characteristic of TrPs exclusively -3. TriggShort-term vasodilatation after dry needling of active TrPs was recorded in several cases and it is unknown whether noxious stimulation of every active trigger point can provoke vasomotor reactions. Moreover, the presence of trigger points in sciatica patients secondary to a primary lesion, e.g. a vertebral disc lesion, was suggested . Still, Because the prevalence of TrPs among sciatica patients is unknown, the first aim of this study was to evaluate the prevalence of active gluteus minimus trigger points among subacute sciatica patients. The second aim was to check the hypothesis that dry needling of gluteus minimus TrPs can provoke autonomic response in the area where trigger points refer pain (autonomic referred pain – AuRP).The study was conducted in accordance with the Declaration of Helsinki approved by the Ethics Committee of Poznan University of Medical Sciences no. 630/13). All subjects gave written informed consent to participate in the study before data collection. A detailed description of all examination and treatment procedures, including dry needling (DN), and risks involved in this study, was provided to the participants. Participants had the right to refuse DN treatment and withdraw from the study at any time without penalty. A flow diagram of the study design was shown as Figure 3. All suSeventy eight Caucasian patients (both sexes) with subacute sciatica were enrolled to the study, twenty three of them did not meet inclusion criteria and five refused to participate in the study because of the needle fear. Finally, fifty Caucasian patients  with subacute sciatica (mean age 41.2 ± 9.1y) were recruited to the study consecutively from the University Pain Clinic. All participants were re-diagnosed with sciatica of radicular origin by an independent university neurologist based on clinical bedside examination, extensive neurological screening examination, accompanied by a positive straight leg test and magnetic resonance imaging results. Key inclusion criteria were as follows: diagnosis of sciatica, age between 30 and 60 (inclusive), both lower limbs present, pain duration 1–3 months, >3 on the 1–10 point VAS scale of leg pain, with this being the dominant pain problem. Patients were excluded from the study for a number of reasons, i.e. complex regional pain syndrome, cauda equina syndrome, previous back surgery, spinal tumors, scoliosis, pregnancy, coagulant treatment, disseminated intravascular coagulation, diabetes, epilepsy, infection, inflammatory rheumatologic diseases, stroke, or oncological history.In one week maximum, post neurological examination of all the sciatica subjects was conducted by an experienced specialist for myofascial pain syndrome co-existence – gluteus minimus active trigger points presence based on Travell and Simons’ diagnostic criteria . After tActive trigger points (TrPs) were confirmed if spot tenderness, recognition of pain and digitally evoked referred pain pattern of the gluteus minimus were present. The localization of the two most active TrPs was marked. For the non-TrPs subjects, the two most tender points were marked. According to Travell and Simons, the referred pain pattern of the gluteus minimus muscle (confirmatory sign) is rarely present under digital pressure of TrPs and it is usually evoked when the needle encounters TrPs . Due to Just after trigger points confirmation, every subject received the dry needling procedure under IRT control in the same University IRT laboratory. Dry needling (DN) in the present study is meant to be a potential diagnostic tool. However, DN performed for the purposes of the study may have a potentially therapeutic effect (pain relief), which was not evaluated.All of the patients were asked to define the pain level on the visual analogue scale and to draw their current pain pattern on a diagram. IRT side-to-side comparison of the painful area and the opposite extremity was performed in the standing position.Thermographic images were recorded by an expert following a standard protocol recommended by the Academy of Neuro-Muscular Thermography . The expA thermovision touchless camera (NEC-AVIO TVS-200EX) using a 8-14 μm wave band, temperature resolution better than 0.080°C, sensitivity 80 mK and working in real time was applied. The camera was equipped with a high-speed (60 Hz) uncooled FPA 320x240 (HxV) pixels VOx (vanadium oxide) microbolometer. For data analysis , the specialist program “Thermography Studio 2007 Professional” was used.To obtain the stability of patient body temperature and to ensure the adjustment of the recording camera’s temperature to the interior conditions, the evaluation began 30 minutes after the patient had entered the examination room. Thermal isolation of the evaluated area from other thermal factors that might have influenced the evaluation, including other parts of the patient’s and doctor’s bodies, was ensured. Moreover, when performing thermovision imaging, the general rules of camera usage were followed.The patient’s position for needling of the gluteus minimus muscle was the side lying position. The muscle was needled with flat palpation perpendicular to the muscle along the counter of the iliac crest. Strong depression of the subcutaneous tissue was applied in order to reduce the distance of the skin from the muscle. Depth of penetration depended on the amount of adipose tissue . TherapeThen, all subjects received a dry needling (DN) session under IRT. The time of needling was 5 minutes for every given point. During the whole procedure, the subarea of referred pain reported by the patient  was recorded. After the needling of both marked points was completed, further thermovision imaging was performed. The IRT observation lasted for six consecutive minutes post-DN.sk) changes  in the observed area after the dry needling session during 6 minutes post-DN. Additional analysis assumed the calculation (in cm2) of skin temperature (Tsk) changes above the maximum (vasodilatation) or under the minimum (vasoconstrictions) temperature. The expected vasomotor changes in the area of TrPs related referred pain were named autonomic referred pain (AuRP) if present. The size of each AuRP was recalculated from cm2 to the percentage value.The analysis of thermograms assumed skin temperature ; sciatica without trigger points co-existence (needle sensation). Additionally, the subgroups were analyzed based on gender.According to William Cochran’s assumption for XAs a result, the information about the minimal size of the sample was obtained . However, for the strong evidence of data the examined was n = 50 because the prevalence of trigger point among sciatica patients is unknown. For the strong evidence of data presented, the significance level was set based on the exact tests, not on the default asymptotic method. Exact two-way Mann–Whitney U tests were performed in order to ensure that data are representative of the whole population of possible data values. Tests were applied to compare the differences for maximum, minimum and average skin temperature and the percentage size of expected autonomic phenomena for the state after dry needling and secondly for the post-DN state. Pearson correlation with two-tailed significance test was applied to define the dependency of the autonomic phenomenon occurrence. All comparisons were completed, with trigger points co-existence being the differentiating criterion.Additionally, the two-way Jonckheere-Terpstra test with the same terms was conducted in order to observe the tendency of skin temperature changes and autonomic phenomena occurrence dependent on TrPs, likely TrPs and non-TrPs presence.Values, figures and tables in the text are expressed as ± standard error of the mean (SEs). Significance level was set at p < 0.05. Statistical analysis was performed using IBM SPSS Statistics, version 20".avr) comparison before the dry needling (DN) session revealed ΔTavr of 0.01°C.Based on IRT, side-to-side (painful to non-painful leg) average skin temperature  in the group of subjects was 32.0%. IRT evaluation confirmed short-term vasodilatation for all TrPs positive subjects . The size of AuRP in TrPs-positive subjects was as follows: post-DN 12.3 ± 4.0% and post-observation 22.1 ± 6.1%. Among non-TrPs subjects, only several hot spots were confirmed (post-DN 0.4 ± 0.3% and post-observation 0.4 ± 0.2%). Figure sk increase in the thigh and calf was confirmed for TrPs-positive subjects only. The exact two-way Mann–Whitney U test showed that post-DN and post-observation there were significant increases in average temperature @ and post-observation (1.6 ± 0.3°C) (both p < 0.05)  in all of the measured subareas, namely the thigh, calf and foot Figures  and 4. H @Figure  for the Among non-TrPs subjects (n = 34), some of the patients @(n = 10) reported pain exacerbation following needle infiltration into the gluteus minimus muscle (likely TrPs). The presence of some hot spots above initial maximum temperature was confirmed. The size of AuRP for likely TrPs subjects was: post-DN 0.0 ± 0.0% and post-observation 0.1 ± 0.1%. The percentage size of AuRP area for needle negative non-TrPs subjects was: post-DN 0.6 ± 0.5% and post-observation 0.4 ± 0%.Dry needling provoked skin temperature changes for all non-TrPs subjects in all of the measured subareas, namely the thigh, calf and foot. However, no significant increases in average and maximum temperature were confirmed Figure .The two-way Jonckheere-Terpstra test revealed a significant positive tendency for AuRP presence  depending on TrPs presence. The mean value of AuRP percentage area was: 0.61 ± 0.45% for non-TrPs, 0.0 ± 0.0% for likely TrPs and 12.25 ± 3.97% for TrPs-positive subjects. Similarly, for skin temperature changes the two-way Jonckheere-Terpstra test revealed a significant positive tendency for: thigh maximum temperature increase , thigh average temperature increase @ and calf average temperature increase  dependent on trigger point presence.avr increase  and calf Tavr increase  dependent on trigger point presence and needle reactions.The two-way Jonckheere-Terpstra test revealed a significant positive tendency for AuRP presence  depending on TrPs presence. The mean value of AuRP percentage area was: 0.44 ± 0.31% for non-TrPs, 0.12 ± 0.12% for likely TrPs and 22.07 ± 6.10% for TrPs-positive subjects. Similarly, for skin temperature changes the two-way Jonckheere-Terpstra test revealed a significant positive tendency for: thigh TThe present study demonstrated that active trigger points co-exist in around one in three subacute sciatica patients. This is the first study examining the significance of active trigger points in subacute sciatica patients. However, the co-existence of active trigger points in nonspecific low back pain and cervical radiculopathy was confirmed ,18.Nevertheless, the most important result of the present study is that dry needling under IRT control provoked a TrPs related significant temperature increase (p < 0.05) and revealed short-term vasodilatation corresponding to the subject’s pain distribution Figure . MoreoveThe presence of autonomic phenomena in the area of trigger point referred pain, e.g. vasomotor, pilomotor, etc., was considered an extremely rare state, limited to severe active TrPs only. The results of the present study are opposite. All subjects presented short-term vasodilatation when TrPs co-existed. Moreover, the AuRP covered on average around one-fifth of the lower extremities subarea Figure . Such exAdditionally, IRT side-to-side comparison of subjects before the procedure indicated the norm and there was no difference between TrPs-positive and -negative subjects. This can explain why previously the usefulness of IRT was controversial ,21.Moreover, the results of the present study are opposite to those of Zhang et al. and Kimura et al., who presented latent TrPs related vasoconstriction after nociceptive stimulation under laser Doppler flowmetry control rather than IRT detectable skin temperature changes ,11. IRT Another important aspect is that every TrPs-positive sciatica subject developed short-term vasodilatation, which indicates the involvement of the sympathetic nervous system (SNS) in trigger point pain propagation, which was suggested before . AdditioTaut band presence and pain recognition are the two most important clinical criteria of trigger point diagnosis, and referred pain is a confirmatory sign. Due to the anatomy of the gluteus minimus muscle, the taut band is mostly not accessible but TrP spot tenderness can be clearly localized. However, it was reported that the referred pain pattern can be induced by the needle encountering TrP rather than by sustained pressure . The posThe results of the present study indicate the biphasic nature of AuRP. The dry needling session was followed by a further increase in skin temperature and spreading of vasodilatation Figure . The exaThe theories put forward by Lewis and Hong ,29 can gThe presence of dry needling related vasodilatation in all TrPs is quite promising with respect to the possibility of using IRT as an objective TrPs confirmation tool. However, it is important to check if all TrPs within muscles can develop vasodilatation. Additionally, the presence of AuRP indicate the involvement of the sympathetic nervous system in pain propagation in sciatica patients. Nevertheless, it is not known how clinically important TrPs presence in this group of patients is. Further studies are still required.The significant prevalence of TrPs among subacute sciatica subjects was confirmed. Although observed vasodilatation was characteristic of all TrPs-positive subjects, for strong methodological evidence a cross-over study is required. Assessment of DN influence on healthy subjects and IRT observation without DN are needed. Additionally, female fertile phase and its possible impact for the autonomic response should be observed in the future.The presence of active TrPs within the gluteus minimus muscle among subacute sciatica subjects was confirmed. All TrPs-positive sciatica patients presented DN related vasodilatation in the area of referred pain. Moreover, the presence of TrPs related autonomic phenomenon suggests the involvement of sympathetic nerve activity in myofascial pain pathomechanism. Although the clinical meaning of TrPs in subacute sciatica patients is possible, further studies on a bigger group of patients are still required.


The sacroiliac joint (SIJ) is a common source of low back pain. However, clinical and functional signs and symptoms correlating with SIJ pain are widely unknown. Pelvic belts are routinely applied to treat SIJ pain but without sound evidence of their pain-relieving effects. This case-control study compares clinical and functional data of SIJ patients and healthy control subjects and evaluates belt effects on SIJ pain.17 SIJ patients and 17 healthy controls were included in this prospective study. The short-form 36 survey and the numerical rating scale were used to characterize health-related quality of life in patients in a six-week follow-up and the pain-reducing effects of pelvic belts. Electromyography data were obtained from the gluteus maximus, biceps femoris, rectus femoris and medial vastus. Alterations of muscle activity, variability and gait patterns were compared in patients and controls along with the belts’ effects in a dynamic setting when walking.Significant improvements were observed in the short-form 36 survey of the SIJ patients, especially in the physical health subscores. Minor declines were also observed in the numerical rating scale on pain. Belt-related changes of muscle activity and variability were similar in patients and controls with one exception: the rectus femoris activity decreased significantly in patients with belt application when walking. Further belt effects include improved cadence and gait velocity in patients and controls.Pelvic belts improve health-related quality of life and are potentially attributed to decreased SIJ-related pain. Belt effects include decreased rectus femoris activity in patients and improved postural steadiness during locomotion. Pelvic belts may therefore be considered as a cost-effective and low-risk treatment of SIJ pain.NCT02027038ClinicalTrials.gov  The sacroiliac joint (SIJ) is the source of low back pain in 15% to 30% of patients with non-radicular pain . Though Furthermore, morphological or functional correlates of SIJ pain are widely unknown , 26. OnlAccording to the guidelines of the international association for the study of pain, dysfunctions of the SIJ should primarily be managed non-surgically with surgical interventions being limited to treatment-refractory cases , 34, 35.Our present study investigates clinical and functional data of SIJ patients to healthy age-matched control subjects and immediate pain-relieving effects of pelvic belts in a dynamic setting and compares the muscle activity and gait pattern data when walking. Additionally, short-form 36 survey data were obtained in a six-week follow up to quantify belt-related health effects in SIJ patients. It was hypothesized that pelvic belts are capable of decreasing SIJ-related pain and improving health-related quality of life in SIJ patients in a six-week follow up. It was further hypothesized that pelvic belts alter muscle activity, the variability of muscle activity and gait patterns and that these changes were different in SIJ patients compared to the healthy controls.ClinicalTrials.gov  and 18 age-matched controls without any history of musculoskeletal disorders, enrolled between August 2011 and December 2012 . The patThree Tesla MRI  were obtained from the lumbar spine, the entire pelvis and the SIJ as well as both hip joints from all participants to rule out inflammatory causes of SIJ pain or extra-articular pathologies that potentially cause comparable symptoms , 44 prioAll participants were interviewed on the day of investigation without belt application regarding their health related quality of life by means of the SF36 health survey , 46 Fig. PatientSurface EMG were obtained from the muscles of the dominant leg of all participants simultaneously with video capturing and gait pattern data when walking. The biceps femoris, the gluteus maximus, the medial vastus, the rectus femoris and the tibialis anterior muscle were included with the reference electrode placed at the lateral malleolus of the respective side. The conditions without a pelvic belt and with a pelvic belt under moderate and maximum tension were investigated, recording ten cycles each Figs  and 3A. moderate tension) and maximum tension (ΔRMSmaximum tension):The mean RMS of the condition without pelvic belt  and SPSS version 20.0 . Normal distribution was determined with the Kolmogorow-Smirnow-Test or with the Shapiro–Wilk test. Baseline characteristics and the SF36 subscales were evaluated with Student’s t-test or the Mann-Whitney U-test. A non-parametric test (Friedman test) was used to investigate alterations in the NRS values. The RMS values, their variations and the gait pattern data were compared between SIJ patients and controls with the Mann-Whitney U-test. The Wilcoxon signed-rank test and the Friedman-test with post-hoc analyses were used to compare the data of the different conditions of belt application within the SIJ patients and the controls for post hoc  given the errors .2. Controls had a mean age of 43.7 ± 19.9 years and a mean BMI of 24.2 ± 3.9 kg/m2. Age, body height, weight and BMI did not vary significantly between SIJ patients and controls. The duration of SIJ pain in the patient group averaged 54.5 ± 49.7 months. The NRS scores and further baseline data are given in Data of 17 patients suffering from SIJ pain  and 17 healthy controls  were included in this prospective investigation . The patAnother SIJ patient was excluded after interpretation of the MRI records showed a conflicting gynecological pathology. The dominant side proved to be the (more severely) affected side in 10 of the 17 SIJ patients (58.8%) with the corresponding muscle data being evaluated in this study. The RMS data, RMS variability data and the gait analysis data were not normally distributed.z = 0 (Δz < -1) than the healthy reference (z = 0). Also, the SIJ patients were less constrained in the mental and social subscales , bodily pain (p < 0.001), physical summary (p < 0.001), and also in vitality (p = 0.011) and social functioning (p = 0.004), as indicated by the SF36. Comparison the SF36 physical summary of SIJ patients without belt application and controls revealed an effect size ranging between 1.89 and 3.35 and a statistical power of 1.00  for SIJ patients and 17/17 (100%) for the controls. The response rate of the six-week follow-up SF36 for SIJ patients was 15/17 (88%). The control group was similar to the German average population, as indicated by the z-transformed SF36 values close to z = 0 . In the z = 0 . This fi of 1.00 . The effΔz < +0.14; p < 0.001), bodily pain (p < 0.001) and physical summary scores , bodily pain (p = 0.006) and in the physical summary score  higher than the chronic low back pain reference group in physical role functioning, vitality, social role functioning and role emotional functioning subscores, and were closer to the healthy controls than to the low back pain group  without using a pelvic belt but after physical examination, 3.4 ± 2.1 (p < 0.001) under moderate and 4.0 ± 1.9 (p = 0.001) under maximum belt tension, respectively (p = 0.083), no belt to maximum tension (p = 0.763) and moderate to maximum tension (p = 0.285), though no belt to moderate tension showed a clear tendency. Post-hoc effect size and power analyses showed small effect sizes and a lack of statistical power for these comparisons (The SIJ patients’ NRS was 5.0 ± 1.9 for the two-week period before the investigation day and decreased significantly on the investigation day: 4.0 ± 1.8 (ectively . Compariparisons  except fp = 0.02), which was not the case under maximum tension. Comparison of moderate tension and maximum tension in the SIJ patient group further showed that there were significantly different changes in the activation of the rectus femoris (p < 0.01).EMG data of ten SIJ patients and 17 controls were included for evaluating the RMS. Comparison of the  tension . With thpatients , as compThe comparison of the RMS variability showed that variability was always non-significantly larger in the SIJ patients than in the controls. The only exception was the RMS variability of the gluteus maximus under moderate tension, being non-significantly larger in the controls . Pelvic p = 0.03) and tended to be different under maximum tension . Step width tended to be larger in SIJ patients (10.1 cm) than in controls  without belt application.Greater belt tension increased cadence and gait velocity in SIJ patients and in controls Figs ; Table 5p = 0.02) and to the cadence without the pelvic belt . In the controls and under maximum tension, cadence (57.3 steps/min) and gait velocity (3.9 km/h) increased significantly, as compared to the cadence  and gait velocity  to moderate tension Click here for additional data file.S2 File(PDF)Click here for additional data file.S1 Table(DOCX)Click here for additional data file.S2 TableΔz = +1 is ranked one standard deviation higher than the German reference, whereas, a Δz of -1 is ranked one standard deviation lower than the German reference. Mean values ± standard deviations are given.A (DOCX)Click here for additional data file.S3 Table(DOCX)Click here for additional data file.S4 Table(DOCX)Click here for additional data file.S5 Table(DOCX)Click here for additional data file.S6 Table(DOCX)Click here for additional data file.S7 Table(DOCX)Click here for additional data file.


The pain of a severe burn injury is often characterised by intense background pain, coupled with severe exacerbations associated with essential procedures such as dressing changes. The experience of pain is affected by patients’ psychological state and can be enhanced by the anxiety, fear and distress caused by environmental and visual inputs. Virtual Reality (VR) distraction has been used with success in areas such as burns, paediatrics and oncology. The underlying principle of VR is that attention is diverted from the painful stimulus by the use of engaging, dynamic 3D visual content and associated auditory stimuli. Functional magnetic resonance imaging (fMRI) studies undertaken during VR distraction from experimental pain have demonstrated enhancement of the descending cortical pain-control system.Interactive VRET plus conventional analgesics.Passive VRET with conventional analgesics.Conventional analgesics alone.The present study will evaluate the feasibility of introducing a novel VR system to the Burns Unit at the Queen Elizabeth Hospital Birmingham for dressing changes: virtual restorative environment therapy (VRET). The study will also explore the system’s impact on pain during and after the dressing changes compared to conventional analgesia for ward-based burn dressing changes. A within-subject crossover design will be used to compare the following three conditions:Using the Monte Carlo method, and on the basis of previous local audit data, a sample size of 25 will detect a clinically significant 33 % reduction in worst pain scores experienced during dressing changes.The study accrual rate is currently slower than predicted by previous audits of admission data. A review of the screening log has found that recruitment has been limited by the nature of burn care, the ability of burn inpatients to provide informed consent and the ability of patients to use the VR equipment. Prior to the introduction of novel interactive technologies for patient use, the characteristics and capabilities of the target population needs to be evaluated, to ensure that the interface devices and simulations are usable.ISRCTN23330756. Date of Registration 25 February 2014.Current Controlled Trials  The management of severe burns involves meticulous wound care in order to prevent infection. This necessitates regular debridement and dressing changes over a period of days to weeks. This form of wound care is recognised as one of the most painful procedures that can be undertaken, with some patients reporting severe to excruciating pain . Poor acComputer-generated, three-dimensional ‘virtual’ worlds have existed in the fields of gaming, education and simulation for nearly three decades  with appViewing natural environments has been shown to have therapeutic benefits, including improved pain relief and post-operative recovery . Indeed,Acceptance of interactive technologies, including virtual reality, by the users (patients and staff) is dependent on usability , utility and affordability. Developments driven by the gaming industry have resulted in rapid advancements in affordability, portability and ubiquity of computer systems , 20. TheUsing an active human-centred approach to prototype development and considering context, ergonomics and task completion increases the usability and utility of the intervention .Efficacy of our proposed system is based on previous work on VR distraction , 24. UniThe environmental context of burn patients and their carers at QEHB is a teaching hospital with a specialist burns unit. Most patients are in generously proportioned single or double rooms, but most lack windows with a view and natural light. The prototype system must be mobile and easily moved between patient bed spaces, with appropriate decontamination procedures to minimize the risk of cross-infection.The pattern of burn injury will vary between every patient. As patients may have restrictions to movement and hand or arm function, interface devices, such as commercial, off-the-shelf (COTS) hand controllers and gamepads, can be chosen or modified to allow optimum use by those with the greatest functional deficits. Some analgesics, for example opiates and antidepressants, may affect perception and coordination . These fA priority of the prototype design is to ensure that the process of changing the dressing is in no way hindered. The layout of the patient, bed, equipment trolley and nursing staff will vary depending on the location of the burn wounds. The VRET prototype has been configured to allow flexibility in screen location and patient access. Free-flowing water is also used for some dressing changes to enhance tissue and dressing removal. Full immersion in water, or the use of a ‘hydrotank’ is not used during dressing changes at QEHB, removing the requirement for a fully waterproof system .When compared to standard analgesia alone, adjunctive immersive interaction with a virtual environment will reduce pain during ward-based burn dressing changes.The effects on the pain experienced by patients during painful procedures requiring multimodal analgesia but not requiring sedation/anaesthesia.The effects on the anxiety experienced by patients during painful procedures not requiring sedation/anaesthesia.The system’s ability to generate a sense of presence on the part of the VR users1User acceptance experienced by the patients and usability feedback.User acceptance by the clinical staff caring for the patients.To assess the efficacy of the immersive virtual reality system in terms of the following:This study will be a single-centre block-randomised cross-over trial.This study has been approved by the National Research Ethics Service Committee South Birmingham (Reference 13/WM/0205) and registered with the UK Clinical Research Network portfolio (Study ID 15785) and Current Controlled Trials (ISRCTN23330756).The prototype has been constructed using low-cost, commercial, off-the-shelf components Fig. . Wound cat least three in-patient dressing changes.opioid-based analgesia  or inhaled nitrous oxide (entonox) for the dressing change .Inclusion criteria are patients with burns (any cause) admitted to the Queen Elizabeth Hospital Burns Unit requiring the following:Inability to use the VRET equipment .Requirement for general anaesthesia or sedation with ketamine or midazolam.Poor cognitive state .Multidrug-resistant infection .Dressing changes requiring overhead showeringExclusion criteria include the following:The order of intervention will be randomised using block allocation, as is appropriate for the small sample size . A compuThe observed distribution of 33 pain scores in a recent audit is the true distribution of the ‘control’ value.The mean percentage reduction from the control value is 30 for interactive VRET. This value has been chosen as it has been demonstrated that the patient-determined, clinically important improvement reduction in pain experienced corresponds to 33 % reduction in measured pain, using an 11-point numerical rating scale .The mean percentage reduction from the control value is 15 for passive VRET.Both percentage reductions are normally distributed with a standard deviation of 25.The nonparametric Friedman test (with a significance level of 5 %) will be used to compare the pain scores under the three conditions.Using a Monte Carlo method, we estimate that a sample size of 25 patients would provide 99 % power to detect a clinically important effect. The data and assumptions underlying the calculation are as follows:Patients will be informed of the study by their clinical team. Patients meeting the inclusion criteria will be invited to participate by the research team, following which they will have 12 to 24 h to decide whether they wish to enrol in the study, at which point written informed consent will be taken.Each patient will receive each condition; active VRET, passive VRET and control. The order will be randomised prior to the first procedure.Analgesia will be provided as per ward protocol for each intervention and patient requirement prior to dressing change. Dressing changes will be carried out as usual by ward staff. Regular analgesics will be given at set times according to prescription  and, as required, analgesia will be given 30 to 60 min prior to a dressing change. These timings will be recorded. Breakthrough pain is managed by nurse-titrated boluses of intravenous morphine.For conditions utilising the VRET equipment, a member of the research team will set up the equipment in the patient room/bed space and patients will receive a 5 to 10 min tutorial/demonstration prior to their dressing change. The setup procedures for the VRET system will be demonstrated to the nurse undertaking the dressing change to allow evaluation of nursing perception of the system, including ease of use.A member of the research team will remain in the room whilst the dressing change is undertaken by a member of the burn unit’s nursing team in order to detect adverse events or troubleshoot where required. Their intervention will be the minimum possible in order to allow normal clinical proceedings. Following the dressing change, a member of the research team will remove the equipment from the patient’s bed space/room, decontaminate it and store it safely.A researcher, who has been blinded to the intervention, will return one hour following the dressing change, to collect the questionnaire data from the patient on their experience of pain, anxiety and nausea during their dressing change. Despite the disadvantage of relying on recalled pain by the patient, asking patients questions during the distraction activity could impact the efficacy of the analgesic intervention. Likewise, asking questions during the control condition could be distracting in itself. This methodology will be repeated for the two subsequent dressing changes. At the end of the study period, patients will be offered the use of the VRET system for future dressing changes if they found it beneficial.The member of the research team present for the dressing change will then undertake a semi-structured interview and questionnaire of the patient and nursing staff to assess their user acceptance of the prototype VRET system.The primary outcome measure is the worst pain score experienced during burn dressing change . The NRS has been selected as the patient does not have to be able to write, as is required for a graphical rating scale.Average pain scores during dressing change (NRS).Pain score 1 h after dressing change (NRS).Anxiety score during dressing change (NRS).How satisfied were you with your overall pain management during your dressing change?Patient satisfaction with pain control, measured by Likert item in response to the following question:To what extent did you feel the VR equipment was easy to use?Have you enjoyed the VR session?To what extent did you feel you ‘went into’ the virtual world?How satisfied were you with the virtual reality system during your dressing change?Patient usability, measured by Likert items in response to the following questions:Nausea experienced during the dressing change (Likert item).To what extent did you feel the VR equipment was easy to use?To what extent did you feel the VR equipment interfered with clinical care?Nursing satisfaction with interactive distraction system, measured by Likert items in response to the questions:The secondary outcome measures are as follows:All but the nausea assessment has five possible responses: not at all, not really, undecided, somewhat and very much. The nausea Likert item consists of not at all, very briefly, some of the time, most of the time and all of the time. Each Likert item will be analysed individually.Demographic data will include patient age, gender, size of burn, time since injury and pain score before the dressing change.t test.Data will be analysed using IBM SPSS 20.0. Normality will be assessed using the Shapiro-Wilk Test. When comparing the three conditions the repeated measures analysis of variance (ANOVA), assuming normality, or the Friedman test will be used. When comparing passive or active VRET conditions to the control condition, the Wilcoxon signed rank test will be a possible alternative to a paired The study accrual rate is currently slower than predicted by previous audits of admission data. A review of the screening log has found that recruitment has been limited by the nature of burn care, the ability of burn inpatients to provide informed consent and the ability of patients to use the VR equipment.The within-subject design with graded exposure to the VR intervention was chosen to reduce bias within the study, as it reduces the effect of patient-related confounding factors, such as biopsychosocial influences. Unfortunately this design may have consequently reduced the feasibility of accruing participants.Each patient has to receive at least three inpatient dressing changes not requiring a general anaesthetic or ketamine. Those patients who are otherwise well enough to be discharged home return to outpatient clinic for dressing changes, so many only undergo a one or two study-appropriate dressing change following skin grafting and prior to discharge. For logistical reasons, the study is not currently being run in the outpatient clinic. A relatively high proportion of burn patients with longer lengths of stay have self-harmed (mean 22 days). As many as 82 % suffer from mental illness , with maThe majority of surviving patients with a longer length of stay are the older patients (mean 23 days), those with medical comorbidities and those with large burns –35. WhilAt the time of submission of this protocol (10 February 2015), enrolment into the study was ongoing and eight patients had been enrolled.


Psychosocial factors are not routinely identified in physical therapyassessments, although they can influence the prognosis of patients with low backpain. The "STarT Back Screening Tool" (SBST) questionnaire aids in screening suchpatients for poor prognosis in the primary care setting and classifies them ashigh, medium, or low risk based on physical and psychosocial factors.  This study sought to translate and cross-culturally adapt the SBST to theBrazilian Portuguese language and test the reliability of the Brazilian version. The first stage of the study consisted of the translation, synthesis, andback-translation of the original version of the STSB, including revision by theTranslation Group, pretest of the translated version, and assessment by an expertpanel. The pre-final Brazilian version was applied to 2 samples comprising 52patients with low back pain; these patients were of both genders and older than 18years of age. To assess the instrument's reliability, an additional samplecomprising 50 patients was subjected to 2 interviews, and the results wereassessed using the quadratic weighted kappa value. The instrument's internalconsistency was assessed using Cronbach's alpha (n=105), and the standard error ofmeasurement was also calculated (n=50).  Translation and back-translation attained consensus, and only item 6 requiredchanges; the reformulated version was applied to an additional sample comprising52 individuals who did not report any doubts related to this item. The reliabilityof the SBST-Brazil was 0.79 , the internalconsistency was 0.74 for the total score and 0.72 for the psychosocial subscale,and the standard error of measurement was 1.9%.  The translated and cross-culturally adapted SBST-Brazil proved to be reliable forscreening patients according to their risk of poor prognosis and the presence ofpsychosocial factors. Low back pain is a major health problem worldwide, affecting mostly females andindividuals aged 40-80 years. Approximately 11.9% of patients exhibit limitations due tolow back pain for more than 1 day, and 23.2% of patients show limitations for more than1 month1. Most patients with acute low back pain (90%) recover within 6 weeks, butsymptoms remain in 2 to 7% of patients. These symptoms progress into chronic pain, whichaccounts for 75-85% of absenteeism in the workplace-,,,,The emotional and behavioral impact of this pain favors the development of chronicconditions4-6, and some evidence shows that psychosocial factors, including thepatient's perception about the resolution of the symptoms of low back pain and theirassociation with other diseases, difficulty in coping with the disease, lack ofconfidence, pain catastrophizing, and depressive symptoms, are predictive of dysfunctionand interfere with the prognosis of low back painThus, the application of a questionnaire to assess psychosocial factors may enable thestratification of individuals with low back pain and contribute to therapeuticdecision-making. Recently, Hill et al.,,-Several studies have tested the effectiveness of the SBSTHowever, there are few questionnaires available in Brazil to assess the risk of poorprognosis among patients with low back pain influenced by physical and psychosocialfactors. For this reason, the aims of the present study were to translate andcross-culturally adapt the SBST to the Brazilian Portuguese language and to analyze itspsychometric properties of reliability through assessment of intra-rater reliability,internal consistency, and standard error of measurement to provide a reliable tool forscreening individuals with low back pain. Such a tool will afford physical therapistswith a differentiated approach and improve their clinical decision-making skills in boththe clinical and research settings. ,,,The SBST questionnaire is comprised of 9 items. Of these, 4 are related to refererredleg pain, disability, and comorbid shoulder or neck pain, and 5 of the items make upa psychosocial subscale (items 5 to 9) that investigates bothersomeness, paincatastrophizing, fear, anxiety, and depression,Using the SBST in the study, patients were classified as having a high risk of poorprognosis ; medium risk ; or low risk ,,For the purposes of scoring and classification, respondents were given answer optionsof "I agree" and "I disagree" for the first 8 items, which were scored 1 and 0points, respectively. Item 9 had 5 answer options, including "Not at all, Slightly,Moderately, Very much, and Extremely"; the first 3 options were assigned 0 points,and the latter 2 were given 1 point each. Total scores from 0-3 corresponded to a lowrisk. For total scores greater than 3, classification was based on the psychosocialsubscale score (items 5 to 9) as follows: scores ≤3 corresponded to medium risk andscores >3 corresponded to high riskCross-cultural adaptation of the SBST questionnaire was performed using the methodsdescribed by Beaton et al.,The modified SBST versionFirst, the SBST, which was originally developed in English, was independentlytranslated into Brazilian Portuguese by 2 bilingual public translators (T1 and T2)who were native Portuguese speakers and fluent in English; only one of thesetranslators had knowledge about health subjects. The resulting translations (T1 andT2) were then analyzed together with the original questionnaire by the translatorsand the investigators (second synthesis step), resulting in version T12. In the third step, version T12 was back-translated into English by 2 differentbilingual translators (BT1 and BT2) who had no knowledge about the original Englishversion of the questionnaire; these translators were native English speakers residingin Brazil and fluent in Brazilian Portuguese. In the fourth step, all 5 versions  were revisedby the Translation Group, which comprised one physical therapist, 2 orthopedicdoctors, and all 4 translators. The Translation Group consolidated all 5 versions toproduce a pre-final version of the SBST questionnaire. In the fifth step, 2 pretests were performed with the pre-final version to eliminateany item not understood by more than 20% of the sampleA convenience sample was recruited at Wilson Mello Institute, Campinas, São Paulo,Brazil. This sample comprised individuals older than 18 years of age with low backpain, independent of the time elapsed since the onset of their back pain and with orwithout extension of pain to the lower limbs. Individuals with severe clinical problems ,those subjected to lumbar spine surgery within the previous 6 months, pregnant women,and those who could not read or speak Brazilian Portuguese were excluded from thestudy. All patients who agreed to participate in this stage of the study and in thereliability assessment signed an informed consent form and provided demographicinformation, which is summarized in All of the properties corresponding to domain reliability were tested, includingintra-rater reliability, internal consistency, and standard error of measurementTo assess the intra-rater reliability of the SBST-Brazil questionnaire, a differentsample comprising 50 patients with unspecific low back pain was subjected to 2interviews, as recommended by the Consensus-based Standards for the Selection ofHealth Measurement Instruments (COSMIN)The 2 interviews were conducted with an interval of 2 to 7 days, depending on theavailability of the patients, and the SBST-Brazil questionnaire and a numericalrating scale (NRS) for painA pilot study was conducted in which the SBST-Brazil questionnaire was applied to 105patients with low back pain to test its internal consistency using Cronbach's alpha.The initial results, showing a value of 0.59 in the total score and 0.51 in thepsychosocial scale, were considered unacceptableThe SEM was calculated based on data corresponding to the sample that participated inthe first interview for reliability analysis. The SEM does not represent actualchanges in the questionnaire results but instead error in measurementIntra-rater reliability was assessed using the quadratic weighted kappa coefficientwith the corresponding 95% confidence interval (CI). Following the methods of Sim andWrightThe data relative to internal consistency were tested using Cronbach's alpha, withvalues within the 0.70-0.95 range considered acceptableSEM was calculated according to the equation SEM=1.96*SD*√(1 - Kappa) with the95test-retest corresponding 95% CIThe demographic characteristics of the patients involved in the various steps of thestudy are described in Initial cross-cultural adaptation of the SBST questionnaire to Brazilian Portugueseresulted in similar versions, with translations T1 and T2 exhibiting smalldifferences. Analysis of the back-translations showed that versions BT1 and BT2 were quite similarand equivalent to the original version of the SBST questionnaire, thus indicatingthat version T12 was adequate to obtain the pre-final version. The first pretest indicated that only item 6 of the questionnaire required changes,as the statement "Tenho ficado preocupado por muito tempo [Worrying thoughts havebeen going through my mind a lot of the time]" was not understood by more than 20% ofthe participantsThe intra-rater reliability was considered to be substantialThe internal consistency values of the SBST-Brazil questionnaire were also acceptable, and the SEM was rated very good.These results are described in ,Reliable application of foreign questionnaires to the Brazilian population demands theirsystematic and judicious cross-cultural adaptation to the Brazilian Portuguese language.Cross-cultural adaptation of specific questionnaires is not simple, as not onlylanguage-related but also cultural differences between countries should be taken intoconsideration for the validity and reliability of instruments to be preservedThe SBST-Brazil is the first Brazilian questionnaire designed to screen and classifypatients with low back pain as to their risk of poor prognosis relative to physicaltherapy due to psychosocial factors. Although the original version of the SBST wastranslated to other languages, including Spanish, French, Danish, Arabic, Dutch, German,Italian, Polish, Norwegian, Mandarin, Japanese, Swedish, Turkish, Urdu, Welsh, andYorubaIn our analysis, the quadratic weighted kappa value was 0.79 (95% CI: 0.63-0.95), whichindicates that the intra-rater reliability of the SBST-Brazil was acceptable relative tothe classification result and close to the value of the original versionIn regard to the internal consistency of the SBST-Brazil, it is worth noting that thisinstrument focuses on the assessment of psychosocial aspects related to coping that canbe strongly influenced by the psychosocial profile of the sample. Therefore, futurestudies will also be able to establish whether the internal consistency values of theSBST-Brazil remain acceptable in individuals corresponding to the same clinical,diagnostic, or sociocultural strata. The SEM calculated for the SBST-Brazil was classified as very goodThe reliability domain exhibited satisfactory results that were quite similar to thosecorresponding to the original version of the questionnaire, indicating that theSBST-Brazil is reliable for application to the Brazilian population. Use of the SBST can lead to significant differences in the standard treatment providedto different groups of individuals with low back pain in the primary care settingUpon comparing subjective decision-making by clinical experts to the SBST's allocationto risk subgroups, Hill et al.Nevertheless, the SBST has some limitations, including the failure to identifypsychosocial problems in individuals without pain complaints and the inability tospecify the patient's preferences, expectations, and past treatmentsThe SBST can contribute to the initial screening of individuals with low back pain toimprove their treatment, as well as to the performance of clinical studies ofindividuals with low back pain. In addition, based on the present study, otherpsychometric properties of the SBST may also be assessed. The translation and cross-cultural adaptation of the SBST to the Brazilian Portugueselanguage was performed in a satisfactory manner. The resulting SBST-Brazil versionproved to be reliable for use in Brazil, thus contributing to the treatment ofindividuals with low back pain in the primary care setting by screening them for a riskof poor prognosis and taking psychosocial factors into account. Appendix 1


Patients with traumatic spinal cord injury (TSCI) often suffer from different types of pain. However, headaches (HA) after TSCI have not been studied specifically.To examine the HAs among patients with TSCI.The cross-sectional study included individuals with TSCI from 1997 to 2011 who were interviewed via telephone. The interview based on a specifically designed questionnaire.There were 9 women and 64 men (mean age 37.1 ± 10.6 years). The most frequently mentioned pain was HA (71%), followed by back pain (60%) and pain in neck (44%). HAs were more frequent after the trauma compared with the HAs before TSCI (p=0.01). The HAs that arose after TSCI were not related to the concomitant brain injury (p=0.80). The occurrence of HA did not depend on the severity nor the level of the TSCI.The most frequently reported HA located in the occipital, was pulsating and lasted from 1 to 3 hours. The maximal intensity of the pain was 6.9 ± 2.0 according to the Numeric Rating Scale.Due to the HA 85% of the patients were not seen by any physician and their HA was not diagnosed.This is the first study that shows that HA is the most prevalent pain after TSCI. Despite this, the majority of patients are never consulted, diagnosed or appropriately managed due to their HA. This indicates that further studies are needed to provide evidence regarding the causes of HA and their impact on quality of life.No conflict of interest.


Background and Aim. Aparallel, randomized, double blinded, placebo-controlled trial study was designed to assess the efficacy of single low dose of intravenous magnesium sulfate on post-total abdominal hysterectomy (TAH) pain relief under balanced general anesthesia. Subject and Methods. Forty women undergoing TAH surgery were assigned to two magnesium sulfate (N = 20) and normal saline (N = 20) groups randomly. The magnesium group received magnesium sulfate 50 mg·kg−1 in 100 mL of normal saline solution i.v as single-dose, just 15 minutes before induction of anesthesia whereas patients in control group received 100 mL of 0.9% sodium chloride solution at the same time. The same balanced general anesthesia was induced for two groups. Pethidine consumption was recorded over 24 hours precisely as postoperative analgesic. Pain score was evaluated with Numeric Rating Scale (NRS) at 0, 6, 12, and 24 hours after the surgeries. Results. Postoperative pain score was lower in magnesium group at 6, 12, and 24 hours after the operations significantly (P < 0.05). Pethidine requirement was significantly lower in magnesium group throughout 24 hours after the surgeries (P = 0.0001). Conclusion. Single dose of magnesium sulfate during balanced general anesthesia could be considered as effective and safe method to reduce postoperative pain and opioid consumption after TAH. Postsurgical pain is one of the most important issues that could impress on postoperative peace and comfort. Abdominal hysterectomy associated with intense inflammatory response, resulting in moderate to severe postoperative pain perception –4.The major goal in postoperative pain management is to minimize the dose of medications and lessen side effects, while still providing adequate analgesia . PostopeNarcotics are the most common analgesics which are used after the surgeries. But anesthetists are always looking for replaceable methods with fewer side effects and cost , 9, 10. Preventive analgesia is a method initiated before anesthetic procedure in order to reduce the physiological consequences of nociceptive stimulation and medical adverse effects and has been defined as an antinociceptive treatment that prevents establishment of altered central processing of afferent input from injuries. One of the intravenous adjuvant that has been shown potential in preventive analgesia is magnesium sulfate that could be administered with multiple routes or methods and one of those is preventive single low dose , 11–23.Mg has been used for many years in anesthesia and cardiology as an anticonvulsant or antiarrhythmic drug. The mechanism of the analgesic effect of Mg is not clear but interference with calcium channels and N-methyl-D-aspartate (NMDA) receptor seem to play an important role. It seems that analgesic mechanism of NMDA-antagonists is made by preventing nociceptive central sensitization. Another suggesting mechanism is the role of it on reduction of catecholamine release with sympathetic stimulation, thereby decreasing peripheral nociception or the stress response to the surgery. Data illustrate that the NMDA receptor antagonists “like Mg sulfate” have an effect on pain threshold and could prevent pain perception even with low doses (preventive doses) , 24–27.There are few studies and some contradictions on the effect of intravenous magnesium sulfate on postoperative pain control in “total abdominal hysterectomy,” but they have been performed under different anesthetic methods. In 2008, Ryu et al. have demonstrated that coincide use of bolus and continuous infusion of intravenous magnesium sulfate during hysterectomy can reduce postoperative pain and opioid consumption under TIVA  .As it is confirmed, there have been some important differences between TIVA and balanced general anesthesia. In TIVA method, only intravenous anesthetic agents (hypnotics and narcotics) were used throughout the maintenance of anesthesia instead of IV anesthetics and volatile anesthetics. Whereas, balanced general anesthesia is induced with a hypnotic and Muscle relaxant agents and for the maintenance of anesthesia, volatile anesthetic, incremental doses of narcotics and muscle relaxants are used . As it i4). Moreover, Pain perception is multifactorial and depends on culture, gender, race, socioeconomic state, cognition, and previous pain memory.It is necessary to mention that there are some important subjects related to the study performed by Ryu et al.: (a) different techniques of anesthesia , (b) method of “single dosage” versus “bolus + infusion” dosage, and (c) total dosage of intravenous magnesium sulfate  classes I and II.The randomized (computerized), double-blind, placebo-controlled, clinical trial study with IRCT number of Patients who had prior abdominal surgeries, major organ system dysfunction such as kidney dysfunction, neuropathy, or myopathy, hypersensitivity or allergy to Magnesium or other products, opioid addiction, and calcium channel blockers consumption were excluded.All cases who scheduled for elective TAH were included into the study, after approval of Hospital Ethical Committee. The trial has been fulfilled during 1 year (May 2013 and May 2014) at our maternity hospital.n = 20) received 50 mg/kg of magnesium sulfate in 100 mL of normal saline solution “isotonic saline” as preventive dose (single low-dose), just 15 minutes before the induction of balanced general anesthesia, whereas patients in control group (n = 20) received 100 mL of 0.9% sodium chloride solution at the same times.Patients were randomly enrolled to one of the two groups . Block randomization method was used to generate a random list. The magnesium group  and atropine (0.02 mg/kg) at the end of operation. Heart rate and noninvasive blood pressure were recorded over 24 hours after the surgeries. In this clinical trial, patients, surgeon, outcome assessor, and ward nursing staff were blind to the group allocation. Duration of surgeries were not more than 2 hours, so there was no more fluid loss, wasting time, or abdominal stimulation. All surgeries were performed by the same gynecologist surgeon and the same anesthetist. Balanced general anesthesia was induced with the same method and minimal influence on HR and MAP  for two groups. During intraoperative period any changes in HR (heart rate) and blood pressure (BP) were noted precisely. After the operation, patients were transferred to the recovery room and the consciousness and vital signs were evaluated until they are ready to discharge from there. In case of NRS > 4, Pethidine with dosage of 20 mg, was administered as opioid analgesia after the surgeries.All patients received a balanced general anesthesia without premedication. The balanced general anesthesia was induced with intravenous injection of sodium thiopental 5 mg/kg, fentanyl 1 Primary outcomes of this trial were related to pain score monitoring at 0, 6, 12, and 24 hours after the surgeries. Pain scores were evaluated by NRS  with 10 cm length   Figure .The NRS score was recorded at emergence of anesthesia and at 6, 12, and 24 h after the surgery. The dosage and timing of analgesia were recorded at 0, 6, 12, and 24 after operation for two groups accurately. Demographic data , duration of the surgery, and pethidine consumption were recorded over 24 hours after the surgeries exactly. According to the decision of Ethical Committee, pethidine should be administered by anesthetist, in case of NRS > 4. As well as, post-operative nausea and vomiting (PONV), hypotension and symptoms of hypermagnesemia were monitored and noted precisely at the emergence time and first day after the surgeries. Serum level of magnesium was assessed just before the bolus dose and 10 minutes after that. Hypermagnesemia was defined as serum level of magnesium more than 2.5 mEq/L. But in this study, hypermagnesemia was considered if serum magnesium level was more than 7 mEq/L (more than therapeutic dose). Any changes in heart rate (HR) and blood pressure (BP) were noted and monitored precisely during preoperative, intraoperative, and postoperative period.U  test. Two-tiled independent t-test was used to compare mean age, weight, duration of surgery, and dose of pethidine consumption between two groups. A P value less than 0.05 has been considered as significant different.At least 20 patients per group were necessary, to detect a difference in 0.9 cm in pain score between two groups with an error probability of 5% and a power of 80%, assuming a standard deviation (SD) of 1 score. Data were analyzed using IBM SPSS Software Version 21. Data were shown as mean ± SD pain scores in different postoperative times between two groups which were compared using Mann-Whitney  N = 20) and normal saline group (N = 20). All patients completed the trial (P < 0.05). But no significant differences were seen at the emergence time. Also, pethidine consumption in magnesium group was lower than saline group, over 24 hours after the surgeries significantly (P = 0.0001)  .Preoperative mean systolic blood pressure in magnesium group was 128.8 ± 5.29 mmHg and 121.25 ± 11.10 mmHg in preoperative and postoperative period, respectively. Also, mean diastolic blood pressure was 76.0 ± 6.41 mmHg in preoperative period and 74.5 ± 5.60 mmHg in postoperative period.In the saline group, mean systolic blood pressure was 119.25 ± 7.83 mmHg and 129.0 ± 10.71 in preoperative and postoperative times, respectively. Also, mean diastolic blood pressure was 75.25 ± 6.17 mmHg in preoperative period and 74.00 ± 4.17 mmHg in postoperative period. There was no experience of hypotension after the surgeries. None of patients experienced nausea or vomiting throughout 24 hours.In Mg group, serum magnesium level was 2.24 ± 0.50 mEq/L before receiving magnesium and 3.43 ± 0.72 mEq/L, 10 minutes after that time. Therefore, there was not any evidence of hypermagnesemia.Our study has demonstrated that IV preventive dose of magnesium sulfate , just 15 minutes before the induction of balanced general anesthesia, alleviates postoperative pain throughout the first day after the abdominal hysterectomies. Furthermore, opioid (pethidine) consumption has been reduced over that time after the surgeries with no report of nausea, vomiting, hypotension, or hypermagnesemia. As intraoperative pain was measured with control of the heart rate (HR) and mean arterial pressure (MAP), any increases in those items have been considered as pain perception which needed incremental doses of opioids. There was no significant difference on NRS, just at emergence time (it means when they were transferred to the recovery room).Pain after abdominal hysterectomy can be multifactorial. Incision pain, pain from deeper  structures, and, particularly, dynamic pain, such as during straining, coughing, or mobilizing, can be quite severe. In one study, the authors found that visceral pain dominated during the first 48 hours after hysterectomy .Opioids remain the common analgesic drugs after abdominal surgeries but their adverse effects such as respiratory depression, nausea, and vomiting or hypotension make this category of drugs undesirable , 9.Parenteral Mg sulfate has been used for a long time in obstetric and cardiovascular practices, but its role as an adjuvant analgesic during preoperative period specially after total abdominal hysterectomy (TAH) has been in negotiation , 12, 30.There have been numerous studies on the clinical efficacy of magnesium sulfate on postoperative pain relief that have shown conflicting results.Wilder-Smith and colleagues used a perioperative infusion of magnesium levulinate in patients undergoing elective TAH and concluded that preoperative magnesium infusion does not improve postoperative analgesia. A small study group size and inadequate dose of magnesium might have been possible causes of this finding , 21, 32.Lysakowski and colleagues in a systemic review randomized trial reached different conclusions as to whether Mg is a useful adjuvant to postoperative analgesia. Their trials do not provide convincing evidence that perioperative Mg has favorable effects on postoperative pain intensity and analgesic requirement . But, inMavrommati and colleagues assessed the infusion of low dose Mg sulfate in hernioplasty and concluded that preventive lower bolus doses of Mg sulfate are an effective adjuvant for perioperative analgesic management .Ryu and colleagues in a randomized double-blinded study assessed the effect of Mg sulfate on intraoperative anesthetic requirement and postoperative analgesia in gynecologic patients who underwent TIVA  and concluded that IV Mg sulfate improves the quality of postoperative analgesia during TIVA. Results were the same of ours, but maybe the difference was for use of TIVA against balanced general anesthesia .Kiran and colleagues evaluated the efficacy of single-low-dose of IV Mg sulfate for prevention of postoperative pain after inguinal surgery and concluded; it could decrease post operative pain and equivalent of rescue analgesia .Hypotensive effect of Mg explained with its direct vasodilating effect through the calcium channel blockade and rarely observed with Mg up to 60 mg/kg , 14, 26.−1 in 100 mL of normal saline solution alleviate postoperative pain throughout the first day after TAH under balanced general anesthesia significantly and reduce opioid consumption as well.We concluded that IV preventive doses (low doses) of magnesium sulfate with dosage of 50 mg·kg


We used a questionnaire known as the Douleur Neuropathic 4 testand we conducted detailed neurological exams. As a result, 42 patients wereexcluded from the study for not having proved their pain.  Out of the 37 patients that experienced pain, 22 (59.5%) had neuropathic pain (ora mixture of this pain and their existing pain) and of these 90.8% considered thispain to be moderate or severe. 81.8% of the sample suffered with this pain formore than 6 months. Only 12 (54.5%) of the patients had been diagnosed withneuropathic pain and in almost half of these cases, this pain had not beendiagnosed. With reference to medical treatment (n=12) for neuropathic pain, 5(41.6%) responded that they became better. For the other 7 (58.4%) there were nochanges in relation to the pain or in some cases the pain worsened in comparisonto their previous state. Statistical analysis comparing improvements in relationto the pain amongst the patients that were treated (n=12) and those that were not,showed significant differences .  we noted difficulties in diagnosing neuropathic pain for leprosy in that almosthalf of the patients that were studied had not had their pain diagnosed. Weattributed this to some factors such as the non-adoption of the appropriateprotocols which led to inadequate diagnosis and treatment that overlooked the truepicture. The presence of pain is a common characteristic in patients with leprosy. It isresponsible for physical and psychological pain(1). The cause of the pain is connectedto secondary nociceptive stimulus and tissue inflammation which is often triggers offepisodes of immune activation (reverse reaction and erythema nodosoum leprosum).Alternatively there is a neuropathic cause that is secondary to the damage which causesa complete lack of functioning of the nervous system (2).The International Association for the Study into Pain (IASP) defines the pain as beingcaused by lesions or somatosensory nervous system diseases. Neuropathic pain is a typeof pain that has been ignored in the treatment of those with leprosy (3-4). For a longtime it was attributed to inflammatory processes, or even the process of neuralcompression - nociceptive pain, being responsible for the entire pain for this group ofpatients. Erroneous diagnosis ended up being prejudicial for the patients that were not treatedappropriately as well as causing comorbidities such as gastric problems, osteoporosis,neuropathy amongst others. This occurred due to the excessive use of anti-inflammatoriesparticularly corticosteroids. This with analgesics, made up the few tools that healthpractitioners had. The Brazilian Medical Association (AMB) advocates that treatment of neuropathic painshould involve the use of 3 classes of medication namely: tricyclic antidepressants, Phenothiazines neuroleptics and anticonvulsants  that can be associated with analgesics andanti-inflammatories according to the needs of every patient (2) .In the main specialist journals on neuropathic pain for leprosy, we sought to analyzeepidemiological and ethological aspects of this problem, focusing on the prevalences andtrying to infer causal relations or evaluating the psychological state of patients(1-5). Different to previous studies, this study concerned itself with identifying thedifficulties in diagnosing and treating neuropathic pain caused by leprosy as well as tounderstand the main characteristics of this situation.This was a descriptive and transversal study. We started by collecting data from medicalreports and through the application of protocols on 85 patients that were at outpatientunits in relation to leprosy in a large municipality in Brazil in 2013. The project wasapproved by the Ethics Committee at the Medical School in São José in Rio Preto(FAMERP), CAAE 02435120.00005414.Researchers carried out the research after having explained to the participants thereasons for the study. The subsequently signed a Consent Form (TCLE) indicating thatthey took part of the own free will. Then a document was drawn up with demographical andepidemiological data on the patients and on the historical development of the disease,particularly related to diagnosis of neuropathic pain. We developed a scale in relationto the pain and an anatomical localization of the pain as well as noting thecharacteristics of the treatment with special reference to the medication used.-All of the patients included in the study were classified in accordance with thecriteria adopted for leprosy by the World Health Organization (WHO) and they were notbeing treated with Polychemotherapy (PQT) in that they had not received a minimum of 6doses in Paucibacillary form (PB) and 12 doses in Multibacillary form (MB),-At the time of the interview, none of the patients showed signs or symptoms of having areactionary state such as Reverse Reaction (RR) or Erythema Nodosoum Leprosum (ENH). Inorder to obtain a diagnosis of neuropathic pain, patients should complaint of pain thathas not been caused by stimulus and anatomical plausibility - in one or more of theregions related to the affected nerveDouleur Neuropathic 4 Questionary (DN4)questionnaire that was translated and checked by a Portuguese person called Santos et alin 2009. This questionnaire was chosen because of its ease of use, its sensitivity (83%)and its precision (90%) in predicting the presence of pain with the characteristics ofneuropathyWe opted to use the NumericRating Scale - NRS to understand better the intensity and the area of thepain (the process is known as Pain Drawing - PD)(12-13).After having defined the case as stemming from neuropathy we used the Deformities were evaluated using the WHO criteria: Level zero - no deformity, Level 1 -loss of sensitivity in the hands and feet or Level 2 - visible motor deformity,including lagophthalmos and the gripping of fingers and contractures and/or ulcers onthe hands and feet(14).In The results were analyzed using the Microsoft Excel statistical program 2013 and GrafPad Instat 3.00/1997. We checked the significance of the results through the test t forStudents, for parametric variables and Mann-Whitney for the non-parametric variables,where appropriate. We considered the limit of statistical significance to be the valueof p≤0,05. Out of the 85 patients who had leprosy that we studied, 37 (43.5%) were in a painfulnociceptive state and/or were neuropathic and 48 (56.5%) were excluded for not havingcomplained of pain or for just having referred to it in the past.After having applied the questions to diagnose the cause of the pain to be neuropathicin the 37 patients who complained of pain, we noted that 12 of them did not match up tothe inclusion criteria  and wereThe following are details on the profile of those affected by neuropathic painrelated to leprosy in our study: 14 (63.7%) were women and their age varied from 24to 66 years old, with an average age of 51 . Fifteen (68.1%) patients that were affected showed a form of MB. We noted that forthose who had been diagnosed for a long period of time there was a greater frequencyof neuropathic pain. 14 (63.7%) had known about the disease for more than 5 yearswith 11 (50%) having undergone PQT for more than 5 years. The existence or previousexistence of a reactionary state did not show that this in itself had any bearing onthe neuropathic pain.The clinical characteristics are shown below in Out of the 22 patients included in the study for having neuropathic pain caused byleprosy, 10 (45.5%) were misdiagnosed cases. Dermatologists gave diagnosis in 66.6%of the cases. There were no mistakes in the diagnosis  on the part ofthe medical assistant.All of the diagnosed patients received, at some point,treatment with medication recommended for cases of neuropathic pain. Tricyclic antidepressants were the most used class of medication. At one point, allof the 12 cases treated received a prescription for amitriptyline. Two patientsstopped using the medication due to somnolence, dry mouth and constipation. Onepatient stopped the having the treatment believing that the medication for thetreatment was for depression.Two patients failed in obtaining improvements for their pain due to insufficientdoses of amitriptyline, being doses below 10 to 25mg per day. The non-usage ofpolytherapy and the use of doses of, on average, 50mg per day explains why there wereno symptoms of improvements.In the class of medications known as anticonvulsants, carbamazepine was used by 8patients. It was subsequently substituted by gabapentine in 1 case and by pregabalinin another since the first medication did not produce the desired results. Thepatients stated that there were improvements after having used pregabalin andgabapentine. Another case of treatment failure occurred with a patient that was undergoingpolytherapy (with amitriptyline + carbamazepine). The patient stopped the treatmentin using carbamazepine complaining of side effects (somnolence and dizziness). Thepatient did not receive other alternative medication that could have been used toresolve the problem. The phenothiazine class of medication was not received by any ofthe patients.None of the 12 patients that were studied (8 of which underwent polytherapy) weregiven the maximum doses of medication used in the treatment of neuropathic pain. Two of the patients obtained their medication through spending their own moneybecause gabapentine and pregabalin is not provided on the Brazilian National HealthService (SUS) .There were improvements for the patients that were treated in comparison to thosethat were not with medication. The information was obtained when they were questioned(n=12), . There were no significant differences in relation to theintensity of the pain and the DN4 points between patients that were treated forneuropathic pain (n=12) and those that were not (n=10). .One in four cases of patients treated for leprosy were affected by neuropathic pain,according to the study . The symptoms are very common according to studies fromChina (2012) and India (2011) which showed frequencies of 45.8% and 21.8%respectively.,This is an important cause of the patients suffering. 90.8% stated that the pain wasmoderate and/or severe and 81.8% stated that they suffered for longer than six months.Nearly half of the cases studied did not have a diagnosis (45.5%). This findinghighlights the fact that neuropathic pain cause by leprosy is not being picked up byhealth care teams. They spend most of their time looking for new cases of the diseaseand using polychemotherapy for existing cases. They deal with reactionary episodes andthe prevention of deformities as well as the controlling communicants What could reduce the failures in diagnosing this condition is the adoption of aprotocol for the identification of neuropathic pain. The DN4 was used in this study. Itwas translated into Portuguese and can be used by any trained professional.Patients symptoms can be minimized where professionals are made aware of the medicationsused for chronic/neuropathic pain and if the cases are handled appropriately.-The use of medications for treatment of neuropathic pain caused by leprosy has not beenfully tested. Random and control tests are needed for class I and II medications whichare not currently covered by medical journals. A good understanding of these therapiescan alleviate symptoms and prevent neuropathic lesions for patients with leprosy-Medication treatment for neuropathic pain (as recommended by AMB) ought to commence withthe application of low doses and then it can be increased on a gradual basis where thepain persists. The herpetic and renal functions of the body need to be monitored.Patients ought to be told of possible side effects. Medication that is cost effectiveand produces benefits should be sought out The Brazilian Government provides some free medication for the treatment of neuropathicpain. They do not cost a lot but medium to high doses cannot taken due to the problemsthat can be caused as they are old medications. The side effects of the medicationaccounted for almost half (42.9%) of the patients terminating their treatment in thisstudy.,The most effective medications such as duloxetine, pregabalin and gabapentine that havefew side effects, are not provided for by the Government. This is due to their highcosts. They are therefore out of reach for the majority of the patients with leprosythat have low incomes in Brazil 7 patients (58.4%) out of the 12 who received medication for neuropathic pain did notexperience improvements in their symptoms. The following were the causes identified forthe failure in the treatment where the medication was used: side effects that caused theuse of inadequate/insufficient doses of the medication, polytherapy not being used incases where the therapeutic responses to a drug was unsatisfactory and an unawareness ofthe benefits of medication that are used for neuropathic pain. The following may alsohave contributed to the lack of improvements: a lack of close monitoring of the patients, unbelief inneuropathic pain diagnosis  and psychosocial causes.The importance of treating neuropathic pain with medication is therefore clear, despitesome of the difficulties. This is because the results showed significant improvements inthe pain compared to those that were not treated. The subjectivity of the symptoms was the main limiting factor in this study. Themultifaceted nature and intensity of the pain means that it cannot be objectivelymeasured. This means that it can be under or over estimated. This can be seen as anotherobstacle that is related to the reduced number of patients with neuropathic pain (n=22).This limits other inferences that can be made based on the results of the study. Thepopulation that has been presented in this study, was treated as outpatients for oneyear in a specific region.During the study, all of the patients that had not been diagnosed with neuropathic painwere given information about the illness. They were then given medication and weremonitored by specialist in chronic pain. We noted difficulties in diagnosing neuropathic pain for those with leprosy in thatalmost half of the patients that were studied had not had their pain diagnosed. One ofthe main reasons for this is because medical staff are not using, on a routine basis, anadequate protocol which would allow them to investigate and effectively diagnosisneuropathic pain. Complications and prolonged suffering is caused by misdiagnosis andinadequate treatment.Neuropathic pain in patients that had been treated with leprosy reached 90.1% of cases.They stated that they had to deal with moderate and severe pain for more than sixmonths. Therefore neuropathic pain for those with leprosy is an important cause forsuffering.The results show significant improvements in the symptoms for those that receivedtreatment in comparison to those that did not. The reasons can be given for those thatstated to be the same or who became worse after the therapy include: the high degree ofside effects, insufficient doses of the medication used, and the non-use of polytherapyin cases in which the therapeutic responses to one drug was unsatisfactory.We therefore conclude that treatment through the use of medication for neuropathic painought to be introduced, despite there not being many systematic and methodologicalstudies in this area. This would go a long way in reducing human suffering.