Back pain represents a substantial burden globally, ranking first in a recent assessment among causes of years lived with disability. Though back pain is widely studied among working age adults, there are gaps with respect to basic descriptive epidemiology among seniors, especially in the United States. Our goal was to describe how pain, function and health-related quality of life vary by demographic and geographic factors among seniors presenting to primary care providers with new episodes of care for back pain.We examined baseline data from the Back pain Outcomes using Longitudinal Data (BOLD) registry, the largest inception cohort to date of seniors presenting to a primary care provider for back pain. The sample included 5,239 patients ≥ 65 years old with a new primary care visit for back pain at three integrated health systems . We examined differences in patient characteristics across healthcare sites and associations of patient sociodemographic and clinical characteristics with baseline patient-reported measures of pain, function, and health-related quality of life.Patients differed across sites in demographic and other characteristics. The Detroit site had more African-American patients (50%) compared with the other sites (7-8%). The Boston site had more college graduates (68%) compared with Detroit (20%). Female sex, lower educational status, African-American race, and older age were associated with worse functional disability as measured by the Roland-Morris Disability Questionnaire. Except for age, these factors were also associated with worse pain.Baseline pain and functional impairment varied substantially with a number of factors in the BOLD cohort. Healthcare site was an important factor. After controlling for healthcare site, lower education, female sex, African-American race, and older age were associated with worse physical disability and all of these factors except age were associated with worse pain.NCT01776242; Registration date: June 13, 2012.Clinical Trials.gov  Back pain is the most common reason worldwide for years living with disability (YLDs) . In the In this study, we addressed these knowledge gaps using baseline data from the Back pain Outcomes using Longitudinal Data (BOLD) cohort of patients aged 65 years and older initiating a new episode of care for back pain . Our priThe study was approved by the Institutional Review Boards (IRBs) of all the participating institutions .We previously described the details of the registry . In brieWe obtained the following patient-reported measures at baseline:Sociodemographic characteristics: age, sex, race, ethnicity, education, employment status, marital status, smoking status and whether they had a lawyer involved with a back-related claim.Pain-related characteristics: a) duration of current episode of back/leg pain ; b) average back pain intensity and average leg pain intensity in the past week on 0–10 numerical rating scales where 0 = ‘no pain’ and 10 = ‘pain as bad as you can imagine’; c) the 24-item Roland-Morris Disability Questionnaire (RMDQ) . Hispanics also reported greater back pain intensity, activity interference, and depression/anxiety.Women reported significantly worse function, pain, and activity interference Figure e and f. Although there were marked differences across sites in levels of education Figure g and h, Patients who had retired or were disabled due to ill health had worse pain and physical function than patients still working. Patients who had retired not due to ill health also had somewhat worse pain and physical function than did patients still working.Table The multivariable analysis demonstrated strong associations of site, employment status, education and duration of symptoms with RMDQ scores after adjustment for other baseline demographic variables Table . We alsoThis is the largest cohort to date of adults aged 65 and older with a new episode of care for back pain. Our results show that there are important differences in pain intensity, physical disability, and health-related quality of life across different healthcare sites and across different patient age, sex, and racial subgroups. These findings are of importance to both researchers and clinicians. For researchers comparing the effectiveness of interventions in observational studies, our findings emphasize the importance of adjusting for any patient baseline differences between treatment groups in factors that are associated with outcome measures of pain, function, and HRQoL. For example, education level appears to be important in this regard, but often is not reported or adjusted for in such studies. Our findings also indicate that identifiable subgroups of older patients may differ substantially at the time of initiating a new episode of care for back pain. This suggests the potential value of applying different interventions tailored to these different subgroups. Moreover, the baseline characteristics of patients and the healthcare system environment in which they are located should be considered when evaluating treatment outcomes.We observed sizable differences in baseline patient-reported measures across recruitment sites, with patients from the Detroit site worse on most measures as compared to the Boston and Northern California sites. Site differences in disability and pain persisted even after controlling for demographic factors available to us. It is possible that unmeasured socioeconomic differences are responsible at least in part for the site differences. Detroit was suffering from a severe economic recession during the study time-frame, and depressed economic conditions have been shown to be associated with poorer well-being and quality of life in the elderly . Our finOur finding that less educated patients reported worse function is concordant with a review by Dionne and colleagues of education and back pain . They spThe finding that women present with worse pain and physical disability than men is consistent with prior research in largely younger populations -24.While there was increasing pain-related physical disability (RMDQ score) with age, pain severity was not clearly associated with age. Prior studies in conditions other than back pain have yielded conflicting findings regarding the association between age and pain severity. Creamer found no association between age and pain severity in a sample of patients with knee osteoarthritis . Thomas Somewhat surprising was that, independent of age, patients who had retired for reasons other than ill health also had worse pain and physical disability than those patients still working. While this might be due in part to the healthy worker effect , other aIn our multivariable analysis, we found that even after adjusting for site, education, pain duration and other factors, African-American race was associated with worse baseline physical disability and pain at presentation for back pain-related care. This finding is consistent with other studies that found worse pain-related disability in cohorts of African-Americans compared with other races -35. ThusPatients with diagnosis codes indicating leg involvement or spinal stenosis reported slightly worse physical disability. This is concordant with other studies indicating that patients with leg involvement have more severe pain and physical disability than those without -38.Adjusting for other variables, as compared with patients who never smoked, those who were former smokers reported somewhat higher levels of physical disability and pain, and current smokers reported even higher levels of disability and pain. Substantial prior research has linked smoking to worse back pain outcomes, and one study of patients with spine-related back or leg pain found that compared with patients who had never smoked, current smokers reported greater pain; in longitudinal analyses, compared with patients who continued to smoke, those who quit reported significantly greater improvement in pain .It is worth emphasizing that our large sample size allowed us to detect what were frequently relatively small differences in patient reported measures between subgroups. The importance of the magnitude of these differences on an individual level is uncertain.One of the limitations of our project is that we enrolled nearly two-thirds of the cohort from a single site – Northern California Kaiser-Permanente. A second limitation is that nearly all of the Hispanics were from one site  and a majority of African-Americans were from another site (Detroit). This distribution of patients limits the overall generalizability of our findings. Differences observed in self-reported measures and outcomes may reflect site-specific differences that are based on local healthcare system or patient-specific factors. Because patients at the 3 sites had different sociodemographic characteristics, we will need to control for these factors in future analyses. A third limitation is that we enrolled 39% of patients initially identified as potentially eligible. Because these patients did not complete questionnaires, we cannot further characterize this non-enrolled group, but we acknowledge that they potentially limit generalizability.Another limitation is that this study was not designed to determine sociodemographic differences between subgroups with low back pain, but rather was designed to examine the natural history of back pain among seniors at three integrated health systems. Subgroup differences may reflect institutional and other local factors that we did not measure, such as income and co-pays, that could influence access to healthcare and hence utilization and outcomes.While ours is the first cohort of seniors with back pain assembled from a primary care setting in the United States, there have been similar cohorts assembled internationally. The Back Complaints in the Elders (BACE)  group isIn summary, we have presented the BOLD baseline results describing the demographic and baseline patient-reported measures. Site was strongly associated with baseline patient reported measures. It is unclear whether site differences were due to geographical factors, socio-cultural factors specific to a particular area, or factors specific to the healthcare system that oversees the care of these patients. Adjusting for site reveals continued association among key demographic variables of race, age, and education with presenting pain. Our results lay the groundwork for future studies involving this cohort.ANOVA: Analysis of variance; BACE: Back complaints in the elders; BOLD: Back pain Outcomes using Longitudinal Data; BPI: Brief pain inventory; BRFSS: Behavioral Risk Factor Surveillance System; HRQoL: Health-related quality of life; ICD-9-CM: International classification of diseases, ninth revision, clinical modification; IRB: Institutional review board; NRS: Numerical rating scale; PHQ-4: Patient health questionnaire for depression and anxiety- 4 item; RMDQ: Roland-Morris Disability Questionnaire; SD: Standard deviation; YLD: Years living with disability.The authors declare that they have no competing interests.Dr. Jarvik has the following potential conflicts of interest, although they do not relate directly to the subject of this manuscript, he lists them in the spirit of full disclosure. He served on the Comparative Effectiveness Advisory Board for GE Healthcare through October 2012. He is a co-founder and stockholder of PhysioSonics, a high intensity focused ultrasound company, and receives royalties for intellectual property. He is also a consultant for HealthHelp, a radiology benefits management company.JGJ, BAC, PJH, JAT, SDS, DRN, SSN, LK, JLF, BWB, ALA, and RAD developed the original concept of the study and developed the design of BOLD Registry study. ZB and KJ participated in the design of as BOLD and are project directors. XS participated in the data analysis and report writing. All authors have read and approved the final version of the article.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2474/15/134/prepubBaseline diagnostic categories and ICD-9 CM diagnosis codes included in each. The diagnoses in italics accounted for approximately 80% of subjects.Click here for file


Tension type headache is the most common type of headache. Although it is not a serious medical condition, in the general population it is the main cause of analgesics use.The aim of this study was to estimate intensity and other qualities of pain as well as the influence of pain on daily functions, the presence of depressive symptoms and their correlation with pain intensity in patients with tension type headache.It was a prospective study performed at the University Department of Neurology, Sestre milosrdnice University Hospital Centre, Zagreb. Patients with tension type headache older than 18y and 30 healthy volunteers were included. Exclusion criteria were: patients younger than 18y, serious physical or mental illness and use of prophylactic therapy for headaches. The intensity and quality of pain were estimated by visual analog scale (VAS),McGill questionnaire,Brief Pain Inventory (BPI) and presence of depressive symptoms by Beck depression inventory (BDI-II). Descriptive statistical methods and regression analysis were used in statistical analysis.The pain intensity in patients with tension type headache was according VAS 51,7+11,86/100mm, McGill questionnaire 15,13+5,06 points and according BPI 1,9+0,86 points. The disability level according BPI was 1,84+1,33 points. The presence of depressive symptoms was 8,76+4,57 points, significantly higher than in the control group . The regression analysis has not shown any correlation between intensity of pain and presence of depressive symptoms.The tension type headache is the chronic pain condition, probably the consequence and not the reason of depressive symptoms.No conflict of interest.


Unsatisfactory analgesia for major knee surgery with femoral nerve block (FNB) alone was reported and the additional benefit of sciatic block to continuous femoral nerve block (CFNB) was not conclusive. The aim of the present study was to find the benefit of the additional mini-dose spinal morphine (0.035 mg) to CFNB for postoperative pain control and to compare their associated side effects after total knee arthroplasty (TKA).After written informed consent and with Institutional Ethics Committee approval, 68 American Society of Anesthesiologists (ASA) Physical Status I-III patients scheduled for elective unilateral TKA under spinal anesthesia (SA) were included in the present prospective, randomized controlled study. The patients were allocated into two groups. CFNB was placed in all patients by the inguinal paravascular approach with 20 ml of 0.25 % levobupivacaine. Group I (named CFNB/SA group), SA was administered with 2.8 ml levobupivacaine and Group II (named CFNB/SAMO group), SA with 2.8 ml levobupivacaine plus morphine 0.035 mg. At Post Anesthesia Care Unit (PACU), pain and other adverse effects were recorded. Pain was assessed by visual analog scale (VAS) 0-10. Tramadol 50 mg intravenous (IV) was given if the VAS > 4. In the ward, all patients were maintained by continuous femoral infusion of 0.125 % levobupivacaine rate 7 ml/hr and then reduced to 5 ml/hr if VAS ≤3.Patient’s demographics data in each group were not different. At post-operative (PO) 12-24 h, the VAS scores were significantly lesser in the CFNB/SAMO group. Cumulative tramadol IV requirement for PO48h were also significantly lesser in the CFNB/SAMO group. Nausea, vomiting and numbness were significantly greater in the CFNB/SAMO group during early postoperative period (PO1-6 h).Though in some patients CFNB was inadequate, a mini-dose of intrathecal morphine (0.035 mg) in addition to CFNB was found to be effective with minimal side effects.TCTR20150609003, date of registration: 6 June 2015).Thai Clinical Trial Registry (identifier:  A large number of patients who undergo knee surgery experience moderate to severe postoperative pain that interferes with participation in early physical therapy –3. SeverThe femoral nerve along with contributions from the sciatic and obturator nerves at the posterior and the medial aspects respectively, provide sensory innervations of the knee. These three terminal nerves are targeted by PNB techniques for major knee surgery , 8–10. RIn response of surgeons’ concerns regarding postoperative sciatic block , we attempted to limit its use. The aim of the present study was to find the effect of adding a mini-dose spinal morphine 0.035 mg (based on our pilot study) to CFNB for postoperative pain control in patients with total knee arthroplasty (TKA).This study was conducted according to the declaration of Helsinki. Informed consent was obtained and documented from the participants before data collection. The final protocol and written informed consent form had been approved by Ethics Committee, Faculty of Medicine Ramathibodi Hospital, Mahidol University. This study has been registered at Thai Clinical Trial Registry (identifier: TCTR 20150609003).After written informed consent and with Institutional Ethics Committee approval from June 2012 to June 2015, 70 American Society of Anesthesiologists (ASA) physical status I-III patients scheduled for elective unilateral TKA under spinal anesthesia (SA) were included in the prospective, randomized controlled blind study. Exclusion criteria included age < 40 years or > 80 years, body mass index (BMI) > 45, renal insufficiency [Creatinine level (Cr) > 1.5 mg/dl], pre-existing neurological deficit, inability to comprehend pain scales, chronic opioid use, and contraindications to either neuraxial block or FNB. The patients were allocated into two parallel groups at a ratio of 1:1, using random number table. All patients were premedicated with oral lorazepam 0.5 mg 1 h before surgery and were sedated with midazolam 1 mg and fentanyl 25 mcg intravenously before conducting anesthesia. CFNB was placed in all patients by the inguinal paravascular approach, 19 G, 50 mm needle . Localized femoral nerve was defined by quadriceps twitch at <0.5 mAmp using a stimulation of 0.1 ms at 2 Hz. After negative aspiration, 20 ml of 0.25 % levobupivacaine was administrated and catheter was inserted 3-4 cm past the cannula. SA was done in lateral position at lumbar vertebrae segment (L) 3-4, 27-G needle. Group I (named CFNB/SA), received SA with 2.8 ml levobupivacaine. Group II (named CFNB/SAMO), received SA with 2.8 ml levobupivacaine plus morphine 0.035 mg. Urinary catheters were placed in all patients and were continued until 24 h post-operative.2), electrocardiogram. The surgical time was noted as the time from incision to the end of surgery. On arrival in the Postanesthesia Care Unit (PACU), pain, and other adverse effects such as nausea, vomiting, pruritus, dizziness, hypotension (30 % reduced from baseline) numbness, and motor blockade were recorded every 15 min. Motor blockade was estimated using a modified Bromage scale . Pain was assessed by visual analog scale (VAS) from 0-10, where 0 = no pain; 1-3 = mild pain; 4-7 moderate pain; 8-10 = severe pain. Tramadol 50 mg intravenous (IV) was given if the VAS ≥ 4.The standard monitoring was used, including none invasive blood pressure, blood oxygen saturation  were treated on demand with tramadol 50 mg IV every 4 h until discharge. The blinded residents made visits at 6, 12, 24, 36, and 48 h post-operative to record adverse effects, pain scores, patients’ satisfaction .Based on the data from Sundarathiti et al. , at 12 hT-test or Mann–Whitney U test were used to compare the data between the two study groups depending on data distribution in each measurement. Nominal variables were analyzed by chi-square or Fisher’s exact test. A p-value < 0.05 was considered statistically significant.Data were recorded and analyzed using SPSS 15 statistical package  for Windows. Results are reported as mean (SD) for continuous variables, where number and percentage for nominal variables. All continuous variables were first checked for normality of data distribution by Shapiro-Wilk test. Independent samples A total of 68 patients participated, 33 with spinal anesthesia and femoral catheter, and 35 with the same procedure plus intrathecal morphine. Patient’s demographics data Table  in each p-value = 0.01). As presented in Fig. p < 0.05). Patients in both groups had similar overall incidences of other side effect such as pruritus, dizziness and hypotension  except the incidences of numbness during PO1-6 h which was significantly greater in the CFNB/SAMO group . Patient’s satisfaction rated as good or excellent was not different between the two groups.The VAS scores and the number of patients suffering from ‘moderate to severe pain’ are presented in Tables th hour after surgery (approx. 40 vs. 15 %) but not any further  to complete the analgesia without any more effort and care on the side of the anesthesiologists. The pain scores (VAS) 6, 12, 24 and 48 h after surgery and the cumulative tramadol IV requirement  of 3.96 % and a rate of malposition after correct placement of 15.2 %. Among others we have to contemplate the possibility of secondary block failure, where the catheter has not been positioned appropriately. Although the block was achieved with the stimulation technique, the trigger during stimulation applied in this study with < 0.5 mA was probably too high. In addition the initial dose of local anesthetics might have been too low and unnoticed catheter migration could also lead to failure. Inadequate efficacy of FNB alone for knee surgery is due to the fact that the posterior part of the knee is innervated by the sciatic nerve. Hence sciatic block has been added to FNB by many study groups [The effect of CFNB in this study was not satisfactory, because the VAS scores in both groups were quite high Table . Category groups –14, thouThe purpose of our study was to find a simple ‘multimodal’ form of postoperative pain control, using a technique that can be added to femoral catheter in patients with major knee surgery under spinal anesthesia. Multimodal analgesia combines alternative strategies with the goal to avoid routine parenteral narcotics, and minimize the side effects of the respective method –18. It tIntrathecal opioids added to local anesthetics during spinal anesthesia have been applied in a variety of surgical settings since 1979 . In an aAchieving high quality pain relief after TKA is possible using regional anesthesia and multimodal pain management . In patiPostoperative analgesia with continuous femoral block (CFNB) alone for total knee arthroplasty (TKA) is inadequate. A mini-dose of intrathecal morphine in addition to CFNB was found to be simple, safe, inexpensive and more effective than CFNB alone for managing postoperative pain after TKA with little side effects. However, the analgesic effect could be better. Future studies have to determine the most appropriate dose of spinal morphine when added to proper working femoral analgesia.ASA, American Society of Anesthesiologists; BMI, body mass index; CFNB, continuous femoral nerve block; CFNB/SAMO, continuous femoral nerve block with mini-dose spinal morphine; Cr, creatinine level; EA, epidural analgesia; ITMO, intrathecal morphine; ITOA, intrathecal opioid analgesia; IV, intravenous; PACU, post anesthesia care unit; PNB, peripheral nerve block; PO, post-operative; PONV, post-operative nausea and vomiting; SA, spinal anesthesia; TKA, total knee arthroplasty; VAS, visual analog scale.


Cervical radiculopathy is a common neuro-musculo-skeletal disorder causing pain and disability. Traction is part of the evidence based manual physical therapy management due to its mechanical nature, type of traction and parameters related to its applicability and are still to be explored more through research. Our objective was to determine the Effects of Mechanical versus Manual Traction in Manual Physical Therapy combined with segmental mobilization and exercise therapy in the physical therapy management of Patients with Cervical Radiculopathy.This randomized control trial was conducted at department of physical therapy and rehabilitation, Rathore Hospital Faisalabad, from February to July 2015. Inclusion criteria were both male and female patients with evident symptoms of cervical spine radiculopathy and age ranged between 20-70 years. The exclusion criteria were Patients with history of trauma, neck pain without radiculopathy, aged less than 20 and more than 70. A total of 72 patients with cervical radiculopathy were screened out as per the inclusion criteria, 42 patients were randomly selected and placed into two groups by toss and trial method, and only 36 patients completed the study, while 6 dropped out. The mechanical traction was applied in group A and manual traction in group B along with common intervention of segmental mobilization and exercise therapy in both groups for 6 weeks. The patient’s outcomes were assessed by self reported NPRS and NDI at the baseline and after completion of 06 weeks exercise program at 3 days per week. The data was analyzed through SPSS version-21, and paired T test was applied at 95% level significance to determine the statistical deference between two groups.Clinically the group of patients treated with mechanical traction managed pain , and disability (mean pre 24.43 and mean post 7.26) more effectively as compared with the group of patients treated with manual traction . Statistically the results of both mechanical and manual traction techniques are equally significant in group A and B for pain and disability .If patients of cervical radiculopathy treated with mechanical traction, segmental mobilization, and exercise therapy will manage pain and disability more effectively than treated with manual traction, segmental mobilization, and exercise therapy. Cervical radiculopathy is a common neuro-musculo-skeletal disorder causing pain and disability. Pain perceived as arising in the arm caused by the irritation of cervical spinal nerves or its roots is considered as radicular pain and termed as radiculopathy, and 1 out of 1000 individuals suffer from cervical radiculopathy.2Manual Physical Therapy is a part of conservative management and effective in managing pain, joint restrictions and disability, while applied in combination with therapeutic exercises.5It is also evident that Manual traction techniques combined with cervical mobilization improves pain and manages disability in patients with cervical radiculopathy as compared with mobilization alone.This randomized control trial was conducted at department of physical therapy and rehabilitation, Rathore Hospital Faisalabad, from February to July 2015. Inclusion criteria were both male and female patients with cervical spine involvement, evident radicular symptoms, and age ranged between 20-70 years. Patients with history of trauma, neck pain without radiculopathy, aged less than 20 and more than 70 were excluded. The total of 72 patients with cervical radiculopathy were screened out as per the inclusion criteria, 42 were randomly selected and placed into two groups by toss and trial method, and only 36 patients completed the study, while 6 dropped out. Out of 36 patients, 24 (66%) were male and 12 (34%) female, and age ranged 21-62 years and mean age 45.78 years.Mechanical and manual are two commonly used types of tractions techniques were applied in two different groups of patients in combination with segmental mobilization and exercise therapy. The outcomes were assessed by numeric Pain rating scale (NPRS) for pain and neck disability index (NDI) for function. NPRS is a valid and reliable tool for the assessment of pain in patients with neuro-musculo-skeletal problems.10The mechanical traction was applied in group A and manual traction in group B along with common intervention of segmental mobilization and exercise therapy in both groups for 6 weeks. Mechanical traction was applied in supine position by manually adjusted mechanical traction equipment, with 10 second pull and 5 second rest for 10 minutes in single session in group A. The traction force was equal to 10-15% of body weight of each patient and calculated prior to intervention. Manual traction was applied in supine position at 25 degree neck flexion with 10 second pull and 5 second rest for 10 times in single session in group B. Followed C-3 to C-7 segments was mobilized by central posterior anterior (CPA) glide in prone position at and each glide was sustained by 5 seconds for 10 reputations per session in both groups. Active Range of motion, stretching and isometric strengthening home exercise program was advised to all patients in both groups. The outcomes of the study were assessed by NRS and NDI at the baseline, and after completion of 06 weeks exercise program at 3 days per week. The data was analyzed through SPSS version-21, and paired T test was applied at 95% level significance to determine the statistical deference between two groups.Clinically the group of patients treated with mechanical traction manage pain , and disability (mean pre 24.43 and mean post 7.26) more effectively as compared with the group of patients treated with manual traction. . Whereas statistically the results of both mechanical and manual traction techniques are equally significant in group A and B for pain and disability  The results as shown in The result of the current study demonstrated that both pain and function were improved in both groups but the group of patients treated with mechanical traction managed pain , and disability (mean pre 24.43 and mean post 7.26) more effectively as compared with the group of patients treated with manual traction , as the outcomes were measured by NPRS and NDI. Statistical results of both the groups were significant , while clinically the mechanical traction shows added improvement in pain and function. The reason is probably the traction force managed by the traction machine is uniform throughout the session while the traction force applied manually is difficult to keep it uniform due fluctuations in muscle activity, which is natural.Langevin and colleagues conducted a randomized control trial on compared the 2 Manual Therapy and Exercise Protocols for Cervical Radiculopathy. The objective was to compare a rehabilitation program with the idea to increase the size of the intervertebral foramen (IVF) of the involved nerve root to a rehabilitation program that doesn’t include any specific techniques thought to increase the size of the IVF in patients presenting with cervical radiculopathy. The outcomes were assessed by NDI, shortened version of the Disabilities of the Arm, Shoulder and Hand questionnaire, NPRS evaluated at baseline, at the end of the 4-week program (week 4), and 4 weeks later (week 8). They concluded that manual therapy techniques and therapeutic exercises are effective in reducing pain and functional limitations caused by cervical radiculopathy.11Fritz and colleagues carried out a randomized control trial with the title exercise only, exercise combined with mechanical traction, or exercise with over-door traction for patients with cervical radiculopathy, with or Without Consideration of Status on a Previously Described Sub grouping Rule. The objective was to investigate the effectiveness of cervical traction along with exercise for targeted subgroups of patients with neck pain. The outcomes were assessed by NDI at baseline 3 months, 6 months, and 12 months. They concluded combination mechanical traction and exercise for patients with cervical radiculopathy enhance function and reduce pain.4Cleland and group conducted a case series on 11 patients and the objective was to examine the outcomes of a consecutive series of patients coming to physical therapy with cervical radiculopathy and managed with the use of manual physical therapy techniques, cervical traction, and strengthening exercises program. The outcomes were measured by NPRS, NDI, Patient-Specific Functional Scale (PSFS), and global rating of change (GROC) at the time of discharge from therapy and at a 6-month follow-up session. Ten out of 11 (91%) demonstrated positive change in pain and function.12It is concluded that if patients of cervical radiculopathy treated with mechanical traction, segmental mobilization, and exercise therapy will manage pain and disability more effectively than treated with manual traction, segmental mobilization, and exercise therapy. Furthermore a study with large sample size and prolonged duration of intervention is recommended.


However, there is no study which has investigated the concurrent effects of warming and adding bicarbonate. Therefore, we investigated pain scores during the injection of warmed lidocaine with bicarbonate during injection for wound management in patients with trauma. A prospective double-blinded clinical trial was designed. 132 patients (27 women), with trauma referring to the emergency department of Al-Zahra Hospital of Isfahan eligible for local anesthesia were recruited. Patients were randomly assigned into three groups of 44 labeled as A, B and C to receive warmed Lidocaine (37° Celsius), bicarbonate-buffered Lidocaine (7.5% Sodium bicarbonate combined with 1% lidocaine with a ratio of 1 to 9 ) and warmed bicarbonate-buffered Lidocaine were used for group A, B and C, respectively. Patients were asked to grade the degree to which they experienced pain during the injection of local anesthesia using a 0 to 10 visual analog scale (VAS). Results of our study showed that there were no significant differences between the three groups with regard to the degree of experienced pain (VAS) during the injection of local anesthesia . The importance of pain relief for optimal patient satisfaction at emergency departments has been repeatedly emphasized; a pain-minimizing method with little anesthesia and short duration is crucial. Lidocaine provides excellent local anesthesia for wound repair and is used quite commonly for outpatient surgery when referring cases to the emergency department.In all three groups there were no significant differences between males and females in terms of experienced pain (VAS) (p >0.05). The results of the present study indicate that the degree to which patients experienced pain during the injection of warmed bicarbonate-buffered lidocaine was not significantly different compared to warmed lidocaine and bicarbonate-buffered lidocaine. This implies the necessity to investigate the other factors that may affect pain relief during the injection of local anesthesia for wound repair.


Optimism is thought to be associated with long-term favourable outcomes for patients undergoing coronary artery bypass graft (CABG) surgery. Our objective was to examine the association between optimism and post-operative pain and physical symptoms in CABG patients.We assessed optimism pre-operatively in 197 adults undergoing CABG surgery, and then followed them up 6–8 weeks after the procedure to measure affective pain, pain intensity, and physical symptom reporting directly pertaining to CABG surgery.p = .042) and fewer physical symptoms following surgery , but not with affective pain, after controlling for demographic, clinical and behavioural covariates, including negative affectivity.Greater optimism measured pre-operatively was significantly associated with lower pain intensity  surgery.•We found that optimism was associated with lower pain intensity after CABG surgery.•We found that optimism predicted fewer physical symptoms after the CABG procedure.•Having positive expectations may promote better recovery following CABG surgery. Optimism is a psychological trait characterised by positive expectations about future outcomes. It is a significant predictor of physical health Coronary artery bypass graft (CABG) surgery is a major procedure in terms of physical severity and patients typically experience pain and discomfort for up to 6 months after the operation Therefore in the current study, we planned to extend the literature in two main ways. Firstly, optimism was measured approximately four weeks prior to surgery, thereby avoiding the confounding effects of the procedure, and providing a more accurate baseline measure of dispositional optimism. Secondly, in addition to pain, we also measured physical symptoms using a patient-based measure specifically designed to assess coronary revascularisation outcomes. This measure allowed us to explore associations between optimism, pain, and elements of recovery specific to CABG surgery which has not previously been tested in the literature. We hypothesised that patients with higher levels of optimism would have less pain and fewer physical symptoms specific to CABG surgery 4–6 weeks post-operatively, controlling for several clinical factors and negative affectivity — a trait thought to confound optimism effects The data we used in this study were collected as part of the Adjustment and Recovery after Cardiac Surgery (ARCS) Study. We carried out baseline assessments when patients attended the hospital for their pre-surgical clinic appointment on average 27.2 days before their surgery. Follow-up assessments took place on average 62.1 days after surgery and were carried out using postal questionnaires. Our inclusion criteria allowed only patients who were undergoing elective CABG surgery or CABG plus valve replacement to participate. CABG surgery included both on-pump and off-pump surgical procedures. Participants had to be able to complete the questionnaires in English, and be 18 years or older. All procedures were carried out with the written consent of the participants. Ethical approval was obtained from the National Research Ethics Service.p < 0.001), and were less likely to have a history of diabetes .Participants were 265 prospective CABG patients who were recruited from a pre-surgery assessment clinic at St. George's Hospital, London. Follow-up data were collected 4–6 weeks after surgery from 215 patients; 2 patients had died, 13 had formally withdrawn from the study, and 35 did not respond to the follow-up questionnaires. Data on the three outcome measures were available for 201–215 patients. In order to carry out analyses of different outcomes on the same sample, we limited the analyses to 197 patients with complete data on all outcomes and covariates. There were no differences between patients who did and did not provide follow-up data in terms of age, gender distribution, ethnicity, smoking status, cardiological factors, total optimism levels, comorbidity or negative affectivity. But patients who were included in the analyses had lower body mass index (BMI) on average  to 4 (strongly agree). Six items (three reverse-scored) were used to derive the total optimism score, so ratings can potentially range from 0 to 24, with higher scores indicating higher levels of optimism. The remaining four questions on the LOT-R are filler items. Cronbach's alpha for the LOT-R for this sample was 0.68.Optimism was measured at baseline using the revised Life Orientation Test (LOT-R), a 10-item self-report questionnaire that evaluates generalised expectations of positive and negative outcomes In sensitivity analyses, we tested separate optimism and pessimism subscales by summing the three items pertaining to optimism and three items pertaining to pessimism respectively. Ratings for each subscale can range from 0 to 12. Cronbach's alpha for the optimism subscale was 0.64 and 0.66 for the pessimism subscale.none) to 3 (severe). Responses are summed, ranging from 0 to 12, with higher scores indicating higher levels of pain. Cronbach's alpha for the affective pain subscale was 0.80.Two components of the McGill Pain Questionnaire — Short Form (MPQ-SF) no pain) to 10 (worst possible pain).The second component of the MPQ-SF that we used measures current pain intensity using a visual analogue scale. Using an adapted version of this scale, patients were asked at the follow-up assessment to rate their present pain intensity on a numerical rating scale ranging from 0  to 4 (a lot). For the purposes of this study, we removed three items from the CROQ that refer to pain in order to avoid confusion between physical symptoms and pain. Responses were summed, ranging from 0 to 32, with higher scores indicating greater negative symptoms. Cronbach's alpha for the 8-item CROQ physical symptom subscale for this sample was 0.71.Physical symptoms were assessed at follow-up using the 11-item post-surgery physical symptom subscale from the Coronary Revascularisation Outcomes Questionnaire (CROQ) www.euroscore.org/logisticEuroSCORE.htm). In addition, the number of grafts that a participant received and whether they underwent cardiopulmonary bypass (yes/no) were also recorded. History of diabetes was taken from medical notes, categorising patients as diabetic or non-diabetic.Cardiovascular history and clinical factors during admission and management were obtained from clinical notes. Clinical risk was assessed using the European System for Cardiac Operative Risk Evaluation (EuroSCORE) 2).Participants were asked to report any longstanding illnesses apart from heart disease prior to surgery ; responses were summed to compute a chronic illness burden variable. Participants were asked to specify their ethnicity by selecting from the following options: white, black or black British, mixed, Chinese, Asian or Asian British, and other ethnic group. As the majority of patients were white (88.3%) we subsequently created a binary ethnicity variable where patients were reclassified into ‘white’ and ‘non-white’ categories. Smoking was measured as a binary variable (current smoker/non-smoker). Body mass index (BMI) was assessed at the pre-operative clinic appointment and calculated using the standard formula  to 5 (I felt this a lot). Adjectives were derived from a factor analysis of affect items. NES comprised terms for anger , depression , anxiety , fatigue  and loneliness . Cronbach's alpha for the NES scale for this sample was 0.91.Negative emotional style (NES) was assessed at baseline using a rating scale comprised of ten negative mood adjectives adapted from Cohen et al. p < .05 for all analyses, with precise p values reported for all test results. All statistical analyses were performed using SPSS version 20.0 .Associations between variables were examined using Pearson's correlations for continuous data and one-way ANOVAs for categorical variables. Associations between dispositional optimism, pain and physical symptom reporting were modelled using multiple linear regressions. Participants with data available for all variables of interest were included in the analyses. We included covariates that might potentially relate to pain and physical symptom reporting including ethnicity, smoking, BMI, diabetes status, chronic disease burden, cardiopulmonary bypass, number of grafts, EuroSCORE, and NES. Results are presented as both standardised and unstandardised regression coefficients and the significance level was set to r = − 0.397, p < 0.001). Optimism was not associated with age, sex, ethnicity, BMI, chronic illness burden, management of diabetes or any other baseline factors in the analyses. Affective pain reporting was positively correlated with NES at baseline . Pain intensity was associated with BMI  and chronic disease burden . Physical symptom reporting at follow-up assessment was positively associated with NES at baseline  and number of grafts .Multiple linear regressions of optimism on affective pain and pain intensity are displayed in p = .025), but the relationship was no longer significant in the fully adjusted model (p = .18).Optimism was associated with less affective pain in an age and sex-adjusted model  independently of NES, and clinical and demographic factors included in the model. This suggests that patients lower in optimism experience more intense pain at 6–8 weeks post-surgery. BMI was also independently associated with pain intensity at follow-up assessment .We found that optimism scores were negatively associated with pain intensity experienced at 6–8 weeks after CABG surgery  after adjusting for NES, clinical and demographic factors. This suggests that patients higher in optimism experience fewer physical symptoms pertaining to the CABG procedure. Number of grafts also emerged as an independent predictor of physical symptom reporting .We found a negative association between optimism and physical symptom reporting at 6–8 weeks after CABG surgery . However, pessimism subscale scores were significantly associated with physical symptom reporting  suggesting that those higher in pessimism were more likely to report more symptoms pertaining to CABG 6–8 weeks after the procedure.We found that the optimism subscale was not associated with physical symptom reporting .Some studies have assessed the separate contributions of the optimism and pessimism items on the LOT with health outcomes Overall our findings are in line with the broader research which has reported associations between optimism and pain in several pain-related disorders Mahler and Kulik It has been suggested that those with higher levels of optimism report less pain as they are simply less attentive to pain and better able to adjust to the pain experience Neural imaging studies have indicated that the inferior frontal gyrus, the rostral anterior cingulate, and the amygdala are involved in optimistic behaviours In our study we found no association between optimism and affective pain. The affective dimension of pain is more related to the emotional unpleasantness of the pain experience rather than the actual pain sensation itself The strengths of this study include the prospective design, with optimism being measured approximately four weeks prior to surgery, and pain and physical symptoms being measured 6–8 weeks post-surgery. We used a well-standardised measure of optimism used in the majority of optimism studies There are also a number of limitations. In a meta-analysis it has been shown that the strength of the association between optimism and health is moderated by the nature of the measured outcome, in that effect sizes are stronger when health outcomes are measured subjectively Having positive expectations may promote better recovery following the CABG procedure.In conclusion, our results indicate that a more optimistic disposition predicts less pain and fewer physical symptoms pertaining to coronary revascularisation approximately two months after CABG surgery — the time at which most patients are expected to be able to do most normal activities and return to work 10.13039/501100000274British Heart Foundation (RG/10/005/28296).This study was supported by the None.


Axial spondyloarthritis (axSpA) is a disabling inflammatory joint disease with chronic low back pain (CLBP) as leading symptom. Recognizing axSpA in the large amount of CLBP patients is difficult for general practioners (GP). This evaluation aims to assess the effect of a referral strategy for axSpA in young primary care patients with CLBP by comparing the use of the strategy with usual care. The effect is measured at three different levels; by patient reported outcomes , process and costs evaluation.This study design is a cluster randomized controlled trial with GP as clusters. GPs throughout the Netherlands are invited to participate and randomized to either the intervention or the control group. Patients from participating GPs are invited to participate if they have ever been registered with low back pain, without radiation (ICPC L03) and aged 18–45 years. To be included in the study, patients need to have current low back pain and chronic low back pain (>12 weeks). In the intervention arm a referral strategy for axSpA will be applied in CLBP patients, in the control arm care as usual will be provided for CLBP patients. The referral strategy consists of four easy to use variables. All are questions about the back pain complaints of the patients. Data is prospectively collected in an online database at baseline (T0), 4 months (T1), 12 months (T2) and 24 months (T3). After time point T1 (4 months) patients from the control group will also receive the intervention i.e. the application of a referral strategy for axSpA. The effect of the referral strategy is measured at three different levels, by patient outcomes , process measures (e.g. number of axSpA diagnoses by rheumatologists) and by costs . Our primary outcome is the Roland Morris Disability Questionnaire after 4 months, secondary outcomes are pain and quality of life. Costs will be assessed before and after the use of the referral strategy, to estimate if the use of the strategy will lead to a reduction in health care costs and improvement in work participation.It is anticipated that using the axSpA referral strategy for primary care CLBP patients will increase the quality of life of CLBP patients, will result in more (correct) diagnoses of axSpA by the rheumatologists, and will be cost-effective. Ultimately, the results of this study may contribute to the startup of a national implementation of the axSpA referral strategy to identify timely CLBP patients with axSpA.NCT01944163, date of registration; September 6, 2013  Low back pain (LBP) is one of the most common musculoskeletal disorders affecting up to 85 % of the adults at some point in their lives . In 10–2One of the possible causes of chronic low back pain (CLBP) is axial spondyloarthritis (axSpA) which is a heterogeneous inflammatory joint disease. Two recent studies showed a prevalence of axSpA among young 18–45 years) CLBP patients between 16 % and 24 % 5 years C. MoreoveWithin the field of rheumatology several models to identify patients at high risk for axSpA have been published, these models combine multiple predictors, such as clinical symptoms, patients’ characteristics and test results to estimate the probability of the disease. Almost all published referral models are tested in a pre-selected population with a high prior probability of axSpA. Only one referral strategy is developed and externally validated in a primary care CLBP population, the CaFaSpA referral rule , 5. ThisAfter development and external validation of a referral rule the next step before application in daily practice is to investigate the impact of the referral rule , 10. SinThis study entails a clinical effect, process and cost evaluation of using the axSpA referral strategy for primary care CLBP patients. The study aims to determine to what extent use of the rule, in comparison with usual care, leads to less disability and pain and improved quality of life in CLBP patients. Second, it evaluates if the referral strategy leads to more diagnosis of axSpA and finally health care costs and work participation will be compared before and after the application of the referral strategy.The study uses a cluster randomized controlled trial design which is carried out in the primary care setting in the Netherlands. Sixty primary care practices will be randomized to either the intervention or the control  group. Each cluster contains the GPs from one practice and their included patients.GPs at the surrounding areas of participating Dutch rheumatologists will be invited to participate by an invitation letter. Two weeks after this invitation letter a member our research team will call the GP to assure if the GP was interested in participating. The only exclusion criteria for GPs is not using the International Classification of Primary Care (ICPC) coding system for their patients, as patients will be selected from the GP practice using the ICPC system. The ICPC is the standard for coding and classification of signs, symptoms and complaints in general practice. The Dutch ICPC is managed and maintained by the Netherlands Society of General Medical Practitioners (NHG). At present, most general practice information systems use the ICPC codes.Patients will be recruited from participating practices by searching their records for patients with ICPC L03 and aged between 18 and 45 years. The recruitment of patients is the same for GPs randomized to the intervention as for GPs randomized to the control group. All selected patients will receive a letter from their GP briefly explaining the study and asking the patient to respond using the attached return form. If the patient does not respond to the invitation within 4 weeks, a second invitation letter will be sent.Age 18–45 yearsEver registered with low back pain, without radiation ICPC L03Current low back pain≥12 weeks low back painThe inclusion criteria are:A clear explanation for the back pain Mentally incompetent (inability of a person to make or carry out important decisions regarding his or her affairs)No understanding of the Dutch language (written)The exclusion criteria are:Patients who agree to participate sign a consent form, thereafter they will be called by a research assistant to confirm the inclusion criteria. The research assistant will register the answers to the CaFaSpA referral rule of the participant. After this telephone contact the patient will receive online questionnaires per email concerning their back pain. If email contact it is not possible, the patient will receive the questionnaires by post.Those who do not wish to participate will be registered by gender, date of birth and the reason for not participating, such as no current low back pain, no time, etc.Primary care practices are randomly allocated to either the intervention or the control group. Randomisation is stratified for number of GPs working in the primary care practice (one or two vs more than two) to ensure similar number of patients in both groups. The block randomisation schedule is computer generated and administrated by an independent person, who is not involved in patient care. It is impossible to blind patients or GPs for allocation. If a patient receives the advice of a referral to the rheumatologist, both the patient and the GP are actively involved in this referral. Also the outcome assessment is not blinded, as patients assess the outcomes themselves by filling in questionnaires. Blinded analyses of the data will take place when possible.The intervention is the application of the CaFaSpA referral rule by GPs in young primary care patients with CLBP . 5]  the usual care CLBP patients and their GPs will receive a letter containing the outcome of the referral rule and an advice to refer or not refer the patient. After receiving the outcome of the referral rule the patients of the control group will be followed for two years, data will be collected after 1 and 2 years of exposure to the referral rule, this will be sixteen and twenty-eight months after inclusion of the study  (directly after inclusion of a patient in the study), after 4 months T1), after 12 or 16 months (T3) and after 24 or 28 months (T4)  pain o Health related quality of life measured by the SF-36 version 2 and EQ-5D , 15.o Disease activity for axSpA, measured by the BASDAI .o Neuropathic components related to back pain measured by the painDETECT Patient reported outcomeso Diagnosis of axial spondyloarthritis made by rheumatologists, which is verified by hospital records.ProcessiMTA Productivity Cost Questionnaire iPCQ)) [o Loss of work-productivity measured by work participation (e iPCQ)) iMTA Medical Consumption Questionnaire [o Health care resources use measured by the ionnaire CostsThe primary clinical outcome is the score on the Roland Morris Disability Questionnaire (RMDQ) after 4 months . The RMDThe compliance of patients is optimized by sending up to three reminders emails, asking the patient to fill out the online questionnaires. If the patient still has not completed the questionnaires the research assistant will contact the patient by telephone and the questionnaires are sent to the patient by post.For the power calculation we assumed a difference of 2.5 points on the RMDQ at four months between the referral rule and usual care group. These 2.5 points are the clinically significant difference, found in previous studies , 21. Thex2)would be required for 80 % power.Patient in the intervention group who have a negative result of the referral strategy  will receive the same treatment as the usual care group. Therefore, the effect of the referral strategy can only be assessed in patients with a positive result of the referral strategy. From the previous CaFaSpA studies we know that around 50 % of the participating patients will have a positive result. Therefore 360 patients need to be randomized  or median (interquartile range) for continuous variables and count (percent) for categorical variables.As this is a cluster-randomized trial mixed effect regression analysis will be used to compare the mean RMDQ score after four months between the intervention and usual care group. Fixed effects include allocation group and result of the referral strategy . As the effect of the referral strategy is expected in the subgroup of patient with a referral advice, an interaction term between allocation group and result of the referral strategy will also be included. A random intercept will be included adjusting for clustering , 25. ThiFor the secondary outcomes we will again use a mixed effect regression analysis to estimate the effect of the use of the referral strategy after 4 months on process level (i.e. the number of axSpA diagnoses by a rheumatologists), pain (VAS pain), quality of life (SF-36 version 2 and EQ-5D) and disease activity (BASDAI). We will use linear regression for continuous outcomes and logistic regression for dichotomous outcomes. Similar to the primary outcome analysis an interaction term and random intercept will be used to take into account interaction between allocation group and referral strategy and clustering. We intended to assess the effect of using the referral strategy also at 12 and 24 months. However, patients in the control group receive also an advice based on the referral rule after 4 months. Contract between the intervention and control group is no longer present. Therefore, individual trajectories will be modeled using random effect regression with patient outcome as the dependent variable and time as covariate and a random intercept for patient.For the cost evaluation we will compare costs before and after the application of the referral strategy. We will consider costs of provided health care and costs due to loss of work-productivity. In order to calculate costs, the volume of care will be linked to the actual, integrated cost prices per medical service .p-value of <0.05 will be considered statistically significant. Statistical analyses will be undertaken with STATA.A This evaluation aims to assess the effects on patient outcomes, processes and costs of a referral strategy for axSpA in young primary care patients with CLBP by comparing the use of the strategy with usual care. The study started in July 2014 and the first results are expected in May 2016.There are only a very few impact studies in the field of prognostic research. In a recent review there were 61 development studies and only 2 (3 %) of them also had an impact evaluation , an esseThe main strength of this study is that it provides information on the process outcome  and on the patient outcomes . The combination of process and patients outcomes allows for a better interpretation of findings. An effect in process does not necessarily results in improved patient outcomes. Possible absence of effect in patient outcomes, on the other hand, may be the result of insufficient improvement in the process. Further, the study measures the impact of a validated referral strategy. The referral strategy has already shown to discriminating axSpA patients from other CLBP patients . We haveA weakness of the study is that the contrast between intervention and control groups disappears after 4 months, as patients of the control group are also provided with the advice of the referral strategy. Nevertheless our primary outcome is assessed before the contract between intervention and control group is eliminated. We expect that 4 months is a sufficient period to achieve a substantial improvement in the primary outcome by using the referral strategy in the intervention group. For other outcomes we can use a before after design within patients which is acceptable as the back pain complaints are chronic. Another potential weakness is that patients are selected by a registry, rather than only actively care seeking patients are invited to participate. This can lead to a lower participation rate of the invited patients and a potential selection bias of only severe cases of low back pain. However in the prior CaFaSpA studies, the same approach to select participants by the GP register was conducted and this didn’t result in a more severe low back pain study population . In bothIf this study succeeds in demonstrating an impact of applying the referral strategy for axSpA in young CLBP patients, the potential benefit may be substantial. The care provided to CLBP patients can be improved, it will be easier for GPs to refer the CLBP patient with a high risk for axSpA to the rheumatologist. And an earlier diagnosis of axSpA has favorable outcomes, as several studies have shown that an effective treatment in axSpA patients results in a lower disease activity, improved quality of life and enhanced work participation , 29. AndAxSpA, Axial Spondyloarthritis; BASDAI, Bath Ankylosing Spondylitis Disease Activity Index; CaFaSpA, Case Finding Axial Spondyloarthritis; CLBP, Chronic Low Back Pain; EQ-5D, EuroQol five dimensions; GP, general practioner; ICPC, International Classification Primary Care; iMCQ, IMTA Medical Consumption Questionnaire; iPCQ, IMTA Productivity Costs Questionnaire; LBP, low back pain; RMDQ, Roland Morris Disability Questionnaire; SF-36, Short Form Health Survey; VAS, Visual Analogue Scale; YLD, Years Lived with Disability


Despite widespread popular use of complementary and alternative medicine (CAM) therapies, a rigorous evidence based on the efficacy of compound kushen injection (CKI) for cancer-related pain is lacking. In this study, we evaluated the efficacy and safety of compound kushen injection and provided information for current or future research and clinical application. Sixteen trials were identified with a total of 1564 patients. The total pain relief rate of CKI plus chemotherapy is better than chemotherapy except for colorectal cancer. The treatment groups achieved a reduction in the incidences of leukopenia and gastrointestinal, hepatic, and renal functional lesion. However, there is paucity of multi-institutional RCTs evaluating compound kushen injection for cancer pain with adequate power, duration, and sham control. The quantity and quality of RCTs are lower so that we still have to boost the research level through scientific design and normative report. Pain is the major clinical symptom of cancer patients –3. The mCompound kushen injection (CKI) was approved for the treatment of cancer by the State Food and Drug Administration of China more than 20 years ago. It was also known as Yanshu injection, which contains extracts from two herbs, kushen (Radix sophorae flavescentis) and baituling (Rhizoma smilacis glabrae). The primary components are oxymatrine and matrine . CKI limTwo independent reviewers, including a librarian, conducted a systematic literature search using databases , all from time of inception up to December 2014. A text word search was done in the title and abstract for each concept and combined with the subject heading searches , and then the search was limited to clinical trials. A similar search was done by another investigator independently using PubMed with the search term “cancer pain” and the limits of “clinical trials” and “kushen injection.” Both reviewers also visually scanned the results to manually remove any citations that were obviously irrelevant and also scanned reference lists of the identified articles to identify any additional articles.The inclusion criteria were as follows. (1) Randomized controlled trials (RCTs) of patients with cancer-related pain were selected: the experimental group received compound kushen injection and chemotherapy while control group received chemotherapy only. (2) Outcome assessment included pain-related measurements. (3) No language or blinding restriction was used.The exclusion criteria were (1) reviews, nonclinical studies, and case observations; (2) no RCTs; (3) controlled interventions with TCM therapies as other Chinese herbs or acupuncture; and (4) inability to find the outcome measurements or duplicated citations.The primary outcome was total pain relief rate. The reduction in pain intensity was measured using a numerical rating scale (NRS), visual analogue scale (VAS), or verbal rating scale. The secondary outcomes were quality of life and adverse events at the end of treatment course.The articles that met the inclusion criteria were reviewed by two independent investigators , and relevant data were extracted. Disagreements were resolved by a third reviewer (Xiu-xiu Sang). The methodological quality of RCTs was assessed independently using seven-item criteria according to the Cochrane Collaboration-Cochrane Tool of Risk of Bias. This scale reports adequate sequence generation, allocation concealment, blinding, incomplete outcome data addressed, selective reporting, other biases, and blinding of outcome assessment.I2 test and considered significant when I2 was over 50% or p < 0.1. The random effect model was used for the meta-analysis if there was significant heterogeneity while the fixed effect model was used when the heterogeneity was not significant.Data analyses were performed using the statistical package RevMan 5.0 (Cochrane Collaboration). Dichotomous data were presented as risk ratio (RR) with 95% confidence intervals (CI). Heterogeneity among trials was tested using A total of 167 references were identified through database searches, of which 151 articles were excluded , yielding 16 relevant articles for the systematic review and meta-analysis .A total of 1564 study participants were identified from the 16 trials –23 . The combined effects of 16 independent trial results showed that CKI could relieve pain in patients when compared with chemotherapy . The subgroup analysis indicated that no better improvements were observed after CKI treatment for colorectal cancer . The random effect model was used for statistical analysis. The combined effects of 6 independent trial results showed that CKI had improved the KPS increase rate in patients when compared with chemotherapy alone  (Karnofsky performance status (KPS) increase rate data extracted from 6 studies , 20–22 s= 0.001) .p = 0.68, I2  =  0%). The fixed effect model was used for statistical analysis. The combined effects of 3 independent trial results showed that CKI had improved the KPS scores in patients when compared with chemotherapy   .n = 346, RR = 0.76, 95% CI, 0.64 to 0.90, p = 0.001)    , gastroi= 0.003) , and hep 0.0002) . No seveCancer-related pain is the perception of the effect of therapy, disease status, quality of services, and even survival . Intractp = 0.84). There is a clear need for further qualitative and quantitative research to identify the efficacy of CKI for colorectal cancer.One hundred and sixty-seven studies reviewed were CKI plus chemotherapy in treating cancer-related pain. Sixteen trials were identified as eligible studies for systematic review and meta-analysis. The main findings of the present study were that CKI could improve the total pain relief rate and quality of life of patients with cancer-related pain. Despite the apparent positive findings reported, there is insufficient evidence to support routine use of CKI for cancer-related pain due to the poor methodological quality and the small number of trials of the included studies. Interestingly, the meta-analysis of total pain relief rate about CKI plus chemotherapy for colorectal cancer found no consistent effects with other types of cancer (RR = 0.94, 95% CI, 0.50 to 1.76, It was of special interest that CKI with chemotherapy could reduce the adverse events. No patients dropped out of their test trial due to the adverse events of CKI, which indicated that CKI is safe for clinical use. As we all know, leukopenia, gastrointestinal adverse reactions, alopecia, and bone marrow depressions are the common side effects of chemotherapy. CKI plus chemotherapy achieved a statistically significant reduction in the incidences of leukopenia, gastrointestinal adverse reactions, and hepatic and renal functional lesion . It indiLimitation. The primary outcome in this review was total pain relief rate. However, the measure through subjective qualitative scores such as “markedly effective,” “effective,” and “ineffective” is not internationally recognized. In addition, the reduction in pain intensity was measured using different scales such as NRS, VAS, and other measures. So it is uncertain in assessing the outcome. No study of the included trials reported whether any adverse events relevant to CKI were apparent in patients. Thus, all adverse events must be reported by the researchers participating in a clinical trial of CKI in the future.This systematic review and meta-analysis provides moderate evidence for the effectiveness and safety of CKI as adjuvant therapy for cancer-related pain, and a clinical recommendation cannot be warranted because of the generally low methodological quality of the included studies . CKI mayCKI appears to be able to improve total pain relief and quality of life and seems to have beneficial effects on reduction of side effects in patients compared with chemotherapy alone.


The first line treatment of thyrotoxicosis in our unit is anti-thyroid medication for 2 years – longer if unstable control. Since 2010, we changed the anti-thyroid treatment protocol from block and replacement (B&R) to titration regimen (TIT), after the Cochrane review showed that B&R was associated with similar remission rate but more frequent adverse effects than TIT. We aimed at comparing these 2 regimens in our pediatric patients.Patients who received TIT from 2010 to 2014 for relapse of thyrotoxicosis and previously had at least 1 full course of B&R were reviewed. Those who had less than 2 years of TIT, either because they received surgery or radioactive iodine within 2 years, or they have not yet finished the course, were excluded from analysis.The course of B&R versus TIT was compared within each individual. For those who had previously multiple courses of B&R, the latest course was used for analysis.Occurrence of adverse drug side effects, length of the anti-thyroid treatment course, number of clinic visits and thyroid function tests during the course, and frequency of abnormal free thyroxine levels were reviewed and analyzed by paired t-test.27 patients, who received B&R previously, were put on TIT for relapse of thyrotoxicosis after 2010. 17 patients were excluded from the analysis as they were on TIT for less than 2 years, 9 of them had surgery or radioactive iodine within 2 years after starting TIT.Among the 10 patients  analysed, no significant drug side effect was experienced during both treatment periods. While on TIT, patients required longer duration of treatment  with more clinic visits  and thyroid function tests .They needed more frequent clinic visits  and thyroid function tests  per year. They had higher number of abnormal free thyroxine levels per year . The percentage of abnormal free thyroxine levels dropped insignificantly by 2.6% (p=0.645).The estimated drug cost for 2 year’s B&R was ~397 HKD (51.2 USD / 54.6 AUD), while 2 years’ TIT cost ~177 HKD (22.8 USD / 24.3 AUD).Both B&R and TIT are safe without significant adverse effect. B&R seems more cost effective with shorter treatment duration and less frequent clinical and biochemical monitoring, even drug cost is slightly higher.


Entrapment of the superior cluneal nerve (SCN) in an osteofibrous tunnel has been reported as a cause of low back pain (LBP). However, there are few reports on the prevalence of SCN disorder and there are several reports only on favorable outcomes of treatment of SCN disorder on LBP. The purposes of this prospective study were to investigate the prevalence of SCN disorder and to characterize clinical manifestations of this clinical entity.A total of 834 patients suffering from LBP and/or leg symptoms were enrolled in this study. Diagnostic criteria for suspected SCN disorder were that the maximally tender point was on the posterior iliac crest 70 mm from the midline and that palpation of the tender point reproduced the chief complaint. When patients met both criteria, a nerve block injection was performed. At the initial evaluation, LBP and leg symptoms were assessed by visual analog scale (VAS) score. At 15 min and 1 week after the injection, VAS pain levels were recorded. If insufficient pain decrease or recurrence of pain was observed, injections were repeated weekly up to three times. Surgery was done under microscopy. Operative findings of the SCN and outcomes were recorded.p < 0.05). Ninety-six of the 113 patients (85%) experienced more than a 20 mm decrease of the VAS score following three injections and 77 patients (68%) experienced more than a 50% decrease in the VAS score. Surgery was performed in 19 patients who had intractable symptoms. Complete and almost complete relief of leg symptoms were obtained in five of these surgical patients.Of the 834 patients, 113 (14%) met the criteria and were given nerve block injections. Of these, 54 (49%) had leg symptoms. Before injection, the mean VAS score was 68.6 ± 19.2 mm. At 1 week after injection, the mean VAS score significantly decreased to 45.2 ± 28.8 mm  contains supplementary material, which is available to authorized users. The superior cluneal nerve (SCN) is derived from the cutaneous branches of the dorsal rami of T11-L4 . A relatMaigne ,5 drew aMaigne also drew attention to the spontaneous entrapment of the SCN in an osteofibrous tunnel in the space surrounded by the iliac crest and thoraco-lumbar fascia in LBP . FollowiIt is generally known that injury to the branches of the SCN, as a complication of bone graft harvest from the posterior iliac crest for spinal fusion, is a cause of chronic LBP -17. TresThe purposes of this study were fourfold: 1. to determine the prevalence of SCN disorder in spine clinic patients, 2. to determine the relationship between SCN disorder and fractures in the thoraco-lumbar junction, 3. to evaluate the outcomes of nerve block injections, and 4. to present surgical outcomes in patients who had intractable symptoms.This prospective study was conducted from 2009 to 2013. A total of 834 consecutive patients  visiting the Department of Spine Surgery at our institution with the primary complaint of LBP and/or leg symptoms were registered for this study. Patients with prior bone harvest from the posterior iliac crest were excluded. X-rays of the lumbar spine and thoraco-lumbar junction were taken. When patients had leg symptoms, magnetic resonance imaging (MRI) of the lumbar spine was routinely performed to examine the spinal canal and foraminal pathology.The diagnostic criteria for suspected SCN disorder were the following: 1) the maximal tender point was on the posterior iliac crest approximately 70 mm from the midline and 45 mm from the posterior superior iliac spine where the medial branch of the SCN runs through an osteofibrous tunnel consisting of the thoraco-lumbar fascia and the iliac crest and 2) palpation of the maximally tender point reproduced the chief complaint of LBP and/or leg symptoms. When patients met both criteria, a nerve block injection was performed.At the initial evaluation, LBP and leg symptoms were assessed by VAS and the Roland-Morris Disability Questionnaire (RDQ). At 15 min and 1 week after the injection, VAS pain levels were recorded and the incidence rate of complications was also determined. If insufficient pain decrease or recurrence of pain was observed, injections were repeated weekly up to three times until sufficient pain relief was obtained.Surgery was indicated only when temporal pain relief was obtained after SCN blocks and repetitive SCN blocks failed to produce sufficient pain relief.Surgeries and this prospective study were approved by the Ethics Committee of Yokohama City University and Yokohama Brain and Spine Center. The subjects were informed that SCN release was previously performed exclusively for patients with buttock and/or LBP -14 and hAll surgeries were performed by a senior author (YA). The skin over the operative site at tender points was marked using a marker pen just before surgery. SCN release was performed under general anesthesia, with the patient in the prone position, through a 7-cm oblique skin incision over the iliac crest. An operating microscope was used. While being careful not to injure nerve branches passing through the subcutaneous tissue, the superficial layer of the thoraco-lumbar fascia was opened. One or two branches of the SCN were identified within 5 cm above the iliac crest and were seen to emerge from the lateral margin of the deep layer of the thoraco-lumbar fascia Figure A. SCN brLateral X-rays were reviewed by an experienced spine surgeon (HK) to determine whether there was a fracture in any of the T10 to L5 visualized vertebrae. A fracture was defined as grade 1 by Genant semi-quantitative method  or more .U test, and the paired t-test. The level of significance was defined as 0.05. Analyses were performed using Statcel 2 statistical software, version 2 .Comparisons between groups were made using Fisher’s exact test, Mann-Whitney’s p < 0.05) and older subjects (p < 0.05) were included in the suspected SCN disorder group than in the non-SCN disorder group (Table p < 0.05). Of the 113 subjects, 59 (52%) had only LBP, 53 (47%) had LBP associated with leg symptoms, and 1 (1%) had only leg pain  had their chief complaint reproduced by palpation of the maximally tender point, thus meeting both criteria. These subjects were diagnosed with suspected SCN disorder. Significantly, more women (p < 0.01)  with a mean age of 74.8 ± 10.2 years (age range: 33–94), who experienced more than a 20 mm decrease of the VAS score following up to three times nerve block injections. The prevalence of SCN disorders was significantly higher in patients with vertebral fractures than in the remaining 738 patients without vertebral fractures (26/96 vs 87/738) . At 1 week after the initial injection, their mean VAS score had increased to 45.2 ± 28.8 mm (0–100 mm), still significantly (p < 0.05) decreased compared to their mean VAS score before injection  before the SCN block, with no significant difference from that of the non-SCN group. Fifteen minutes after the initial injection, their mean VAS score was 31.6 ± 27.0 mm (0–100 mm), a significant decrease (–100 mm bp < 0.05). At 1 week after the second injection, their mean VAS score had increased to 38.6 ± 26.2 mm (0–90 mm), still significantly (p < 0.05) decreased compared to their VAS score before the second injection.Fifty-three (47%) of the suspected SCN disorder subjects required additional injections for remaining symptoms or recurrence of pain. Before the second injection, the mean VAS score of these subjects was 50.6 ± 20.9 mm (10–100 mm). Fifteen minutes after the second injection, their mean VAS score had significantly decreased to 23.4 ± 20.7 mm (0–70 mm) (p < 0.05). At 1 week after the third injection, their mean VAS score was 44.6 ± 27.3 mm (0–80 mm), not significantly decreased from that before the third injection.Of these subjects, 28 (25%) required a third injection. Before the third injection, the mean VAS score of these subjects was 43.9 ± 24.7 mm (10–90 mm). Fifteen minutes after the third injection, their mean VAS score had significantly decreased to 23.9 ± 19.3 mm (0–60 mm) (The number of subjects who obtained more than a 20 mm decrease of VAS score after the first injection was 91 (81%), after the second injection 93 (82%), and after the third injection 96 (85%). Similarly, the number of patients who obtained more than a 50% decrease of VAS score after the first injection was 70 (62%), after the second injection 76 (67%), and after the third injection 77 (68%).A complication of the injection, erectile dysfunction (ED), occurred in two cases. One was a 41-year-old male who experienced temporary ED during pain reduction after every injection  required surgical release of the SCN because of intractable symptoms (Table Sixteen subjects (84%) had leg pain or tingling. Of these 16 subjects, 10 reported that the leg symptom was more severe than the LBP. Fourteen subjects had leg symptoms spreading from the iliac crest buttock area and the remaining two had leg symptoms remote from the iliac crest (cases 7 and 19) Figure . Two subn = 6), extension (n = 1), or both (n = 10). Of the 16 cases with limitation in flexion, 10 reported that coupling of rotation or lateral bending to the side contralateral to their symptoms further aggravated their symptoms , decreased from 74 to 35 and from 15.0 to 7.4, respectively. All subjects who had limitation of lumbar motion before surgery reported improvement.Surgical outcomes are summarized in Table In the 16 subjects with leg symptoms, surgery resulted in complete relief in 3 , almost complete relief in 2 (cases 3 and 17), no improvement in 3 , and partial improvement in the remaining 8 cases at least at the 6 months follow-up. Five subjects  had temporal pain relief following surgery, but had recurrence of symptoms within an average of 9.4 months (range: 3–26).p < 0.05). Patients with more than 3 days of effectiveness from SCN blocks had a significantly higher ratio of excellent outcome than the patients with less than 3 days relief .Of the 16 subjects who had leg symptoms, subjects with shorter duration of symptoms (3 years or less) had a significantly higher ratio of excellent outcomes  than the remaining subjects with longer duration (more than 3 years) . During palpation, she reported recurrence of the leg tingling in the calf region. From age 68, the SCN block was repeated 90 times. Every time, she reported reappearance of leg tingling during the SCN block and, soon after, clear improvement in leg tingling that continued for 3 days. Although oral prescription of opioids, lumbar sympathetic nerve blocks, epidural blocks, and facet blocks were also attempted, she reported that SCN blocks worked much better than these. At age 71, she was listed as a candidate for spinal cord stimulator therapy in the Department of Anesthesiology. At this time, we decided that an attempt to surgically release the SCN was indicated.During surgery, three branches were identified passing beneath the thoraco-lumbar and gluteal fascia over the iliac crest. The branches were compressed by the fascia with adhesions and released by opening the fascia. She reported disappearance of leg tingling when she awoke from the general anesthesia. Leg tingling and limitation in lumbar motion have not recurred at 47 months after surgery.A 58-year-old man presented with complaints of severe pain in his right lower leg, which had gradually developed over 10 years. Repetitive spine and knee surgeries were performed for this leg pain, including L4 nerve root decompression at age 48, medial meniscectomy at age 51, L4/5 foraminotomy at age 52, L4/5 transforaminal intervertebral body fusion (TLIF) at age 52, and L5/S1 TLIF at age 58, none of which produce pain relief. The pain was so severe that he often refused to walk. A neurologic examination revealed that the right patellar tendon reflex and the bilateral Achilles tendon reflexes were reduced. No sensory disturbance was apparent even in the buttock area, and bowel and bladder functions were normal. He had point tenderness over the left iliac crest 8 cm from the midline and pain radiating to the posterolateral thigh from this location. SCN blocks were repeated 33 times with consistent but temporary pain relief. SCN surgery was done at age of 60. He noticed disappearance of thigh pain when awakening from the general anesthesia. Two years passed uneventfully, but thigh pain gradually recurred 26 months after surgery.A 41-year-old man presented complaining of bilateral leg tingling with tightness predominantly on the right, which had developed gradually over 1 month following acute onset of LBP. He had a history of posttraumatic thoracic outlet syndrome causing left arm tingling at age 32. Because the arm tingling was not fully controlled by spinal cord stimulation performed at age 34, a first rib surgical resection was done at age 43, resulting in almost complete elimination of the arm symptoms.At first examination, he could walk, but it seemed very painful. Forward and backward bending of the lumbar spine was highly limited, especially forward bending. Pushing on his back proximal to the iliac crests using his hands reduced pain during painful motion  who were admitted to the hospital because of LBP had SCN disorder [From 1930 to 1960, cluneal nerve syndrome was sporadically reported as a cause of LBP ,24-27. SIn the current study, the diagnosis of SCN disorder was made solely based on two clinical criteria: 1) maximal tenderness existing over the iliac crest, even when tenderness also exists elsewhere, for example, at the thoraco-lumbar junction, and 2) the chief complaint being reproduced by palpation of the iliac crest. In our study, 113 (14%) of the 834 patients who registered were diagnosed with suspected SCN disorder. Ninety-one (11%) of these subjects experienced more than a 20 mm decrease in VAS scores after the first nerve block injection and 70 subjects (8%) experienced more than a 50% decrease in VAS scores after the injection. Patients who previously had bone harvested from the posterior iliac crest were not included in our study. It is likely that SCN disorder is not a rare clinical entity and is more commonly the result of spontaneous entrapment of the nerve than a nerve injury during bone harvest, as Trescot stated .Trescot mentioned that entrapment of the SCN caused referred pain down the leg, potentially all the way to the foot, and that this “pseudo-sciatica” would clinically mimic radiculopathy due to lumbar disc herniation or lumbar spinal canal stenosis . Strong Clinical manifestations of leg symptoms are quite variable, especially in area of symptoms and aggravating posture. Strong and Davila described that localization of pain was difficult for the patient . In theiIt is likely that the limitation of lumbar motion and leg symptoms could lead to misdiagnosis and unnecessary spine surgeries. Patients with severe symptoms often present characteristic signs suggesting irritable friction of the SCN under the fascia. Characteristic painful limping and limitation in lumbar motion differ from those seen in spinal disorders. Tightening buttocks often aggravates pain during gait, suggesting that constriction of the gluteus muscles squeezes the SCN at the fascial orifice. Patients often realized that pushing above the iliac crest with their hands reduced symptoms. This suggests that immobilizing the proximal portion of the SCN inhibits a continuous piston-like movement of the SCN under the fascia.Symptoms were often aggravated during flexion. Coupling rotation to contralateral side and flexion further aggravated symptoms. Flexion and contralateral rotation would strain the SCN. Conversely, extension of ipsilateral hip reduced pain during flexion. This may be because hip extension loosens the SCN. On careful observation, this is seen to be a pseudo-limitation of lumbar flexion. On the other hand, SCN patients often reported that extension of the lumbar spine aggravated the symptoms. This is similar to Phalen’s and reverse Phalen’s maneuvers used as screening methods for carpal tunnel syndrome. These characteristic signs are useful as a provocative examination maneuver to screen and differentiate SCN disorders from lumbar disorders. Patients who have true sciatica due to spinal canal or foraminal lesion usually have tenderness in the gluteal regions . Although they may also have tenderness on the iliac crest, palpation of this point would not reproduce the leg symptoms.Spine surgeons should be aware that SCN disorder is not rare and may cause not only LBP but also leg symptoms. The key to diagnosing SCN disorder is palpation of the tender point and determining if this palpation provokes the symptoms even when symptoms are remote from iliac crest. As stated by Strong and Davila, the patient is rarely aware of the presence of a trigger area in the back . SCN bloThe term “osteofibrous tunnel” implies severe constriction in the bony groove as illustrated by Kuniya et al. . In spitPatients with SCN disorders comprised about 10% of all patients presenting with a chief complaint of LBP and/or leg symptoms; thus, this is not a rare clinical entity. Approximately 50% of SCN disorder patients had leg symptoms. Eighty-five percent of SCN disorder patients experienced clinical pain relief from repeated nerve block injections, up to three times, when clinical pain relief was defined as more than a 20 mm decrease in VAS. When patients demonstrated a localized tender point on the iliac crest and palpation of this point reproduced their chief complaints, a SCN block proved to be an effective treatment modality.