Extracorporeal shock waves are high-intensity mechanical waves (500–1000 bar) of a microsecond duration with a morphology characterized by a rapid positive phase followed by a negative phase. Background: Extracorporeal shock waves have been used for pain treatment for various sub-acute and chronic musculoskeletal (MSK) problems since 2000. The aim of this article is to update information on the role of extracorporeal shock wave therapy (ESWT) in the treatment of various pathologies that cause MSK pain. Methods: Given that in the last two years, articles of interest  have been published on less known indications, such as low back pain, nerve entrapments, osteoarthritis and bone vascular diseases, a literature search was conducted in PubMed, the Cochrane Database, EMBASE, CINAHL and PEDro, with the aim of developing a narrative review of the current literature on this topic. The purposes of the review were to review possible new mechanisms of action, update the level of evidence for known indications and assess possible new indications that have emerged in recent years. Results: Although extracorporeal shock waves have mechanical effects, their main mechanism of action is biological, through a phenomenon called mechanotransduction. There is solid evidence that supports their use to improve pain in many MSK pathologies, such as different tendinopathies , plantar fasciitis, axial pain , osteoarthritis and bone lesions . Of the clinical indications mentioned in this review, five have a level of evidence of 1+, eight have a level of evidence of 1−, one indication has a level of evidence of 2− and two indications have a level of evidence of 3. Conclusions: The current literature shows that ESWT is a safe treatment, with hardly any adverse effects reported. Furthermore, it can be used alone or in conjunction with other physical therapies such as eccentric strengthening exercises or static stretching, which can enhance its therapeutic effect. Shock wave therapy is a non-invasive therapeutic procedure in which a single-impulse transient acoustic wave of 1 microsecond duration is applied to different target body regions to produce analgesia and facilitate healing through a mechanism called mechanotransduction .Extracorporeal shock wave therapy (ESWT) was first used in 1980, and its indications were extended from lithotripsy to the treatment of delayed bone healing to chronic pain management in 2000 . PlantarAlthough the physiological mechanisms of its therapeutic effect are not fully understood, shock wave therapy produces a biological effect (mechanotransduction) in its passage through the tissues, achieving an analgesic, osteogenic, neovascular and tissue repair effect. Among the beneficial effects they produce, it is worth highlighting that they produce analgesia, facilitate protein synthesis, increase vascularization, improve cell proliferation, produce calcium destruction in tissue and have a protective effect on cartilage and bone . This haThe aim of this article is to update information on the role of ESWT in the treatment of various pathologies that cause musculoskeletal (MSK) pain, such as tendinopathies, low back pain, osteoarthritis, osteonecrosis, bone vascular diseases and nerve entrapments.A literature search was conducted on 11 August 2023 in PubMed, the Cochrane Database, EMBASE, CINAHL and PEDro, using the keywords “extracorporeal shock wave therapy musculoskeletal pain”, with the aim of developing a narrative review of the current literature on this topic. Due to the large number of references published on the topic (3517), a selection was made in the literature to provide a synthesis based on the strength of the evidence. In those pathologies where there were papers with different levels of evidence, those with high levels of evidence  were selected over those with lower levels of evidence . In those pathologies for which no high-evidence studies had been published, low-evidence studies were included to provide a synthesis of the available clinical information. A total of 1745 articles were found in PubMed, 1461 in EMBASE, 195 in CINAHL, 115 in PEDro and 1 in the Cochrane Database, making a total of 3517 articles identified. After identifying duplicate articles, 149 records were screened. A total of 115 articles were considered of interest because they were closely related to the topic of this article, and 98 articles were finally included in this review. The following articles were included: (1) articles with a high level of evidence, including meta-analyses, systematic reviews and randomized clinical trials; (2) articles published within the last five years and able to provide recent information that was not included in other papers in the literature; (3) articles that deal with less frequent indications of shock waves such as nerve entrapment or bone vascular diseases; (4) articles that detail the protocol of the application of shock waves and that could be used to offer homogeneous clinical recommendations. The remaining articles (34) were excluded . ArticleOf the authors who contributed to this paper, HDLC-R and JMR-B conducted the initial literature search and wrote the first draft of the article. ECR-M, BAR-D and AV-S reviewed the draft and contributed to the final manuscript.The results and critical discussion of the studies included in the narrative review are presented below. The following paragraphs refer to the mechanism of action of shock waves, their method of application and their effect on pain in different MSK processes. Shock waves are rapidly generated pressure waves that travel faster than the speed of sound in the same medium through which the wave propagates. The mechanism of action by which shock waves produce their therapeutic effects is not yet fully understood .The shock wave has two phases, an initial phase of rapid rise (<10 ns) with focus pressures of 50 to 80 MPa, followed by a relatively slow phase (milliseconds) of negative pressure of up to 10 MPa . The curThere are two types of shock waves. Focal shock waves, produced by electrohydraulic, piezoelectric or electromagnetic generators, consist of a negative phase and achieve much higher intensity on a target deep in the tissue to be treated. So-called radial waves are lower-intensity pressure waves generated via a pneumatic mechanism, without a negative phase, and whose highest intensity point is produced on the surface of the applicator . When apIn summary, shock waves produce a decrease in pain, facilitate tissue repair and promote bone healing. However, the physiological mechanism by which they produce their therapeutic effect is not fully understood. Furthermore, there are numerous application protocols in the literature that make it very difficult to know the number of sessions, their interval or the intensity at which shock waves should be applied. This is why more work is needed to present clear methodologies and results and to help standardize the guidelines for the application of the technique.Shock waves should be applied to the affected region. Palpatory techniques or ultrasound localization can be used to localize the segment to be treated. Both options appear to be equally beneficial .2) per pulse and plays a role in the therapeutic effect of the technique [2 [2 is recommended [Application protocols may vary according to the studies reviewed . Table 2echnique . In routnique [2 . To faciommended . Most prommended . In geneIt seems that in order to achieve their analgesic effect, shock wave treatment protocols should last longer than one month. In addition, it appears that shock waves, depending on the pathology, may have a greater analgesic effect when applied as monotherapy versus when applied in conjunction with other interventions . Shock waves induce a tissue repair response, so they require time to achieve their clinical effect . ClinicaIt is recommended that the effectiveness of the technique be assessed at least four months after treatment, as one of its advantages is that its therapeutic effect is prolonged in the long term, more so than other types of therapy . For exaIt appears that the best results with shock wave therapy are achieved in patients younger than 60 years and with a symptom duration of less than 12 months . When asIn addition to clinical monitoring, ultrasound can be used to assess changes in tendon morphology and thickness, calcification or neovascularization. However, there may be a discrepancy between clinical and ultrasonographic findings . The effComplete recovery from chronic tendinopathy is estimated to be around 80% . IschemiHistologically, tendinopathy is characterized by the absence of inflammatory cells, intra-tendon collagenous degeneration, the thinning and disorientation of collagen fibers, neovascularization and hypercellularity with high concentrations of glycosaminoglycans and proteoglycans . Using 2The tendinopathies for which ESWTs have shown efficacy are described below.Calcium deposition in the tendons of the shoulder is a common finding that can occur in up to 7.8% to 13.6% of asymptomatic patients and in 33.3% to 42.5% of symptomatic patients . CalcifyA systematic review analyzing 18 articles (more than 1600 patients) reported an improvement in pain and function with shock waves versus a placebo and other conservative treatments such as TENS (transcutaneous electric nerve stimulation) or physical exercise at three and six months. Intervention with ultrasound-guided percutaneous irrigation appeared to offer better results in the pain and radiological progression of calcification at 1 year . In a clLateral epicondylitis is a very common musculoskeletal pathology due to repeated microtrauma to the lateral epicondylar area of the elbow, usually due to overuse . In addiGreater Trochanteric Pain Syndrome is a syndrome characterized by pain in the lateral aspect of the hip that worsens with walking and lateral decubitus on the affected side. It can be caused by tendinopathy at the level of the gluteus medius or gluteus minimus, trochanteric bursitis or external coxa saltans, and is usually self-limiting or improves with conservative treatment in 90% of cases .Shock wave therapy is reserved for cases where conservative treatment has not improved the clinical picture. A meta-analysis including 13 randomized clinical trials (1034 patients) found that both platelet-rich plasma and shock wave therapy produced a short-term pain benefit (one to three months). Physical therapy with a structured exercise program produced a short-term (one to three months) functional improvement . Heaver Knee soft tissue injuries are often due to tendinopathy or ligament injuries, causing pain and functional limitation that affect gait, running and even quality of life . Knee inA review involving 19 randomized clinical trials found moderate evidence that shock waves significantly reduced pain by an average of 1.49 points on the visual analogue scale compared to different control groups. This effect applied both when shock waves were applied at high energy and at low energy . In a reShock waves also seem to have an effect on parameters related to sports performance in the case of patellar tendinopathy. Shock wave treatment could increase vertical jump distance compared to placebo treatment .Achilles tendinopathy is characterized by a clinical picture of pain, inflammation and functional limitation, and occurs more frequently in men, probably due to their higher levels of physical activity . It is cNumerous conservative treatments are used for Achilles tendinopathies such as ultrasound, electrotherapy, laser, orthoses and exercises. These treatments can be combined with shock waves with good results. For example, it seems that the combination of shock waves and eccentric exercises produces better results than eccentric exercises alone . Also, dPlantar fasciitis is a clinical diagnosis that involves pain in the heel, which may affect the inner or outer area of the heel and increases with standing and walking . Its patShock waves have been shown to be useful in the following problems that cause axial pain.2, the authors found that shock waves immediately produced hyaluronan-rich vesicles, collagen-I and collagen-III, increasing after four hours and maintaining it after 24 h, so they concluded that it could have a role in the regulation of the extracellular matrix [Myofascial pain syndrome is defined as a picture of regional pain with the presence of painful trigger points or taut bands with selective pain on palpation . Some wor matrix . A meta-analysis including 10 randomized clinical trials (477 patients) reported that shock waves had a greater effect on pain than a placebo or ultrasound, with similar effectiveness to other techniques, such as laser, dry needling or trigger point infiltration, on pain or functional improvement .In a three-month prospective randomized study (40 patients), shock wave therapy was compared with a placebo (both patients performed a 45 min exercise program five days a week). It was found that the use of shock waves together with an exercise program appeared to be effective in improving pain in patients with chronic low back pain, although it did not achieve functional improvement .Coccydynia is characterized by pain in the coccyx and/or coccygeal joints that worsens with prolonged sitting and occurs most frequently after trauma . In a caDegenerative osteoarthritis is the most common MSK disease. Its pathophysiology involves a series of cellular reactions involving inflammatory mediators, cytokines and matrix degradation. This results in damage to cartilage, the synovial membrane, subchondral bone, ligaments and joint muscles, leading to pain, joint limitation and functional restriction .2) seems to have better results in terms of pain and function, with no difference found between receiving 2000 and 4000 pulses per session [A meta-analysis involving 32 randomized clinical trials (2408 patients) found that shock waves achieved a greater reduction in pain and function than a placebo, oral medication, ultrasound, hyaluronic acid , intra-articular corticosteroids and platelet-rich plasma  . In a ra session .Shock waves have been shown to be useful in the following bone conditions.2; group two received extracorporeal shock wave treatment with an EFD of 0.70 mJ/mm2; and group three received surgical treatment. The clinical and radiographic outcomes were assessed for up to 24 months, and all three treatment groups were found to have similar results [The effects of shock waves at the level of consolidation became known when in 1988, it was shown that patients treated with shock waves during lithotripsy had an increased pelvic osteogenic response. It is now used successfully, and radiological guidance is recommended to localize the application site . In a ra results . The pos results .It appears that the effectiveness of shock waves in the treatment of bone consolidation problems depends on the type of nonunion. Hypertrophic long bone nonunions have an improvement rate of 80% to 100% with shock waves, while atrophic nonunions have a lower response rate estimated to be around 23% to 27% [Femoral head osteonecrosis is a disease with an unknown pathogenesis that can occur in different body regions and is characterized by a pathological increase in interstitial fluid, probably secondary to a vascular reaction to an internal or external process . In someA meta-analysis including six randomized clinical trials (256 patients) reported that shock wave therapy appears to produce an improvement in pain and function in osteonecrosis of the femoral head, especially in the early stages (ARCO stage I and ARCO stage II), and the clinical benefits are maintained in the long term. Adding treatment with prostaglandin inhibitors or bisphosphonates does not seem to improve outcomes . HoweverIn a case series with 22 patients, shock wave therapy was found to offer an improvement in pain, mobility and magnetic resonance imaging (MRI) after 60 days .In a study involving 44 athletes , shock wave therapy was found to improve pain and function at one and three months compared to a placebo. In addition, the treatment group was able to resume sporting activity  earlier (73.2 days versus 102.6 days) .In a retrospective study of 46 patients who had received conservative treatment, surgical core decompression or shock wave treatment was assigned. All patients recovered clinically at 12 weeks with no pathological findings on MRI at six months, but the shock wave treatment group had a greater improvement in pain and resumed daily activities earlier . AnotherSurgical intervention of the median nerve in the carpal tunnel by releasing the flexor retinaculum is the definitive treatment for carpal tunnel syndrome and is effective in the medium and long term .A systematic review analyzing 10 studies involving 433 patients (501 wrists) found that shock waves would be effective in improving pain, other symptoms and function in patients with carpal tunnel syndrome. Radial shock waves would have better results than focal shock waves . A meta-Although the evidence supporting the effectiveness of shock waves seems clearly favorable, there are some limitations in the studies that should be improved. As mentioned previously, there is a lack of unified protocols to apply to the same clinical indications and to be able to draw solid conclusions. Furthermore, many studies compare shock waves with different conservative treatments. Due to the variability in the conservative treatments used in different studies  it is difficult to establish the role of shock waves compared to other therapies ,64,69,75In general, shock wave therapy has been widely studied and there are numerous high-evidence studies such as systematic reviews and meta-analyses. However, there is great heterogeneity in the application protocols and great variability in the conservative and interventional treatment techniques with which the effectiveness of the technique is compared. Furthermore, in many cases, the exact parameters of the intervention are not detailed , nor are the therapies received by the control group . Furthermore, given that the biological mechanisms by which shock waves produce their therapeutic effect are not yet known in depth, the quality of the evidence generated for this technique must continue to be improved.Among the usual contraindications of shock wave treatment are anticoagulant treatment or disorders that favors bleeding (since a high-intensity shock wave can produce bleeding). Other contraindications include acute infection, pregnancy or direct application to the growth plate. Nerve tracts and large vessels should be avoided during application . The vasIt is convenient to apply shock waves over a number of sessions and at a suitable intensity, and performing the technique with an excessive dose can increase the risk of adverse effects occurring  and thatThe contraindication for tendon ruptures is not well established. In general, shock wave therapy is not recommended when there is a complete tendon rupture, but the treatment of extensive tendon injuries (>6 mm or >50%) has been performed without significant adverse effects . One stuA summary of contraindications for shock wave therapy is shown in This is a narrative review in which the articles selected were chosen as the most important in relation to the title of this article, prioritizing the studies with the most scientific evidence . Although there are many mechanisms of action described for shock waves, the complete mechanism is not yet fully understood, nor are the most effective application protocols. In fact, there is great heterogeneity in application protocols, which makes comparison between studies difficult. There are still aspects that have not been sufficiently investigated in the literature and that could help to better understand the role of shock waves in the management of musculoskeletal diseases. Although the effect of shock waves seems clear, the physiological mechanisms by which it acts are not yet fully understood. Furthermore, at a clinical level, it is necessary to have more articles that unify the application protocols to be able to carry out homogeneous studies. On the other hand, it is advisable to better understand the role of shock waves when combined with other conservative therapies. There is still a lack of high-quality articles on certain less frequent indications, and it is important to better study the safety of shock waves when there are tendon ruptures.Further evidence on the efficacy of shock wave therapy in the treatment of musculoskeletal pathologies that cause pain is desirable in the future. It is also essential to have more data on the best treatment protocols to help apply the technique optimally. Due to the numerous mechanisms of action of shock waves, it is expected that new clinical indications in musculoskeletal pathologies will continue to emerge.Extracorporeal shock waves are a non-invasive, safe and effective treatment that can be applied to a large number of MSK pathologies in which the usual conservative treatment has failed. Of the clinical indications, calcific tendinopathy of the shoulder, lateral epicondylitis, greater trochanteric pain syndrome, plantar fasciitis and delayed bone healing present a level of evidence of 1+. Patellar tendinopathy, Achilles tendinopathy, trapezius myofascial syndrome, low back pain, avascular necrosis of the hip, osteoarthritis, femoral head osteonecrosis, pubis osteitis and carpal tunnel syndrome present a level of evidence of 1−. Although their mechanism of action is not completely known, their biological effects at analgesic, osteogenic and tissue-reparative levels achieve an improvement in pain and function that can be maintained in the long term. There is still no consensus on the application protocols for the different MSK conditions, so there is some variability in the recommended number of pulses, intensity, number of sessions and frequency. It is desirable to have more articles studying the role of shock waves in MSK medicine, and for them to be carried out with a more homogeneous methodology in order to obtain more solid clinical conclusions.


About 95% of human body serotonin synthesis occurs in the gastrointestinal tract (GI). Lack of sufficient serotonin levels is thought to play a key role in mood disorders, including anxiety disorders. In this study, we looked at a disorder affecting the GI tract, irritable bowel syndrome (IBS), and aimed to determine whether IBS is differentially associated with anxiety disorders in 252 chronic pain patients in the presence of a history of alcohol use disorders (AUD) given that alcohol is an extremely aggressive substance for the GI mucosa. We found that while the prevalence of IBS was not affected by the presence of AUD in chronic pain patients, IBS had significantly higher comorbidity with anxiety disorders in chronic pain patients with comorbid alcohol use disorders. We argue that these findings highlight mechanistic differences in the comorbidity of anxiety disorders with chronic pain and AUD, implicating a central role for GI problems stemming from chronic alcohol use. The findings may have important implications for the treatment of IBS patients with AUD who commonly present with anxiety disorders which could motivate the continuation of problematic drinking and impede recovery success. We propose that addressing GI problems in patients with AUD may help manage AUD and recovery more effectively. It has Somatically, anxiety appears as an increased heart rate, faster breathing, increased GI tract motility, sweating, sleep deprivation, and many other symptoms. This is primarily due to the activation of the sympathetic nervous system initiated by the amygdala , which sAdditionally, animal studies show that psychosocial stressors can induce visceral hyperalgesia, activate the hypothalamic–pituitary–adrenal axis and alter mitochondrial activity within the GI tract . AdditioIrritable Bowel Syndrome (IBS) is one of the most common functional GI disorders , 17. TheAlcohol is a strong cellular toxin in any amount that disrupts mitochondrial energy processes. It is a highly aggressive substance for the GI tract mucosa . The tox2.2.1.The Institutional Review Boards of the Massachusetts General Hospital approved the research. The sample for this study was chosen from the patients evaluated at the Mass General Brigham, consisting of 16 member institutions ranging from academic medical centers and specialty hospitals to community and urgent care centers. As the first step, the International Classification of Diseases (ICD9 and ICD10) diagnostic codes used for claims submitted for billing purposes were used to identify cohorts of interest that were: (1) AUD and Chronic Pain (AUD + CP), and (2) Chronic Pain Only (CP) cohorts. All the ICD9 codes were mapped to ICD10 codes. For AUD, F10.*, and chronic pain, G89.4 and G89.29 ICD10 codes were used. For the AUD + CP cohort, a set of patients with AUD-related codes but no CP-related codes were also identified to capture patients who may have had CP as noted in their clinical notes but had not received a billing code for it. From the patients identified per each cohort, 200 records were chosen randomly by generating 200 indices between 1 and n  via a random number generator, sorting the cohort by medical record numbers (MRN), and choosing the MRNs corresponding to the randomly chosen indices. This produced a sample of a randomly selected set of 200 patients per cohort with a roughly even distribution across the initially identified lists.2.2.The final patient groups were identified from the sample of patients described above based on an extensive review of the medical charts and the following criteria: The presence of AUD was confirmed if all of the following criteria were satisfied: at least one billing code for AUD existed; there was at least one visit related to alcohol use disorder in the patient’s records; and AUD was mentioned in the clinical notes. The presence of CP was confirmed if all of the following criteria were satisfied: at least one billing code for chronic pain existed, and there was a mention of chronic pain in the clinical notes related to one or more of the following conditions in the chronic form: back pain, neck pain or cervicalgia, joint pain including knee pain, shoulder pain, and hip pain, chronic abdominal pain, arthritis pain, neuropathic pain, fibromyalgia, and cervical myofascial pain. Headaches, including migraine, tension, cluster, or post-traumatic headaches, were not considered chronic pain, and if a patient suffered from chronic headaches only, they were not classified as a CP patient and were omitted. We also excluded cases in which the pain was linked to malignancies.2.3.The presence of anxiety disorders was based on a review of the narrative clinical notes as the primary reference for determination. Anxiety disorders were determined based on persistent complaints (more than 6 months) of feelings of worrying, irritability, fear for the future, fear for health and life, trouble with falling asleep and keeping asleep, difficulties with concentrating, and inability to relax. Patients with situational anxiety or panic attacks were excluded from the cohort. However, the final anxiety group included some patients with panic attacks and situational anxiety since these symptoms were the satellite complaint. We also considered the following ICD10 codes: F41.1, F41.3, F41.8, and F41.9. If there was no mention of anxiety disorder in the clinical notes, but a patient had received one of the noted ICD10 billing codes three or more times, they were labeled as having a history of anxiety disorders.2.4.The presence of IBS was determined by reviewing the clinical notes and examining the associated ICD10 billing codes (K58.*).2.5.The difference in the prevalence rates of anxiety disorders between the AUD + CP and CP groups was determined using the chi-square test. Furthermore, separate chi-square tests were performed to examine the differences in the prevalence of IBS in the presence of anxiety in each group.3.3.1.The billing codes included both ICD9 and ICD10 codes. For analysis and reporting, all the ICD9 codes were mapped to ICD10 codes, which will be used to describe the results in the following. Of the cases identified for the AUD + CP group per review of the narrative clinical notes, 97% also had the associated ICD10 billing codes for alcohol use-related disorders (F10. *). As for chronic pain, 93% of the patients also had an associated ICD10 billing code for chronic pain (G89.4 and G89.29).3.2.The final sample consisted of 101 AUD + CP patients (51 men and 50 women) and 151 CP patients (44 men and 107 women). The majority of patients with AUDs were patients who were followed up at our hospitals for a long time, with 84% of the patients in our cohort evaluated more than three times for AUDs. All patients in the AUD + CP cohort were diagnosed with alcohol abuse as determined per review of the charts and further confirmed by the ICD9 and ICD10 codes they had received. Of all the patients, 71% also had received additional ICD9 or ICD10 codes for alcohol dependence, and 46% had experienced periods of being in remission. The majority of the patients with chronic pain had a history of being on prescribed or over-the-counter pain medication for managing their chronic pain. The two groups had no significant age difference . History of other substance use disorders  was considerably more common in the AUD + CP patients compared to the CP patients (43% vs. 13%).3.3.In the final sample, 29 out of 171 patients identified with anxiety disorders were considered to have a history of anxiety disorders per the associated billing codes only. Of the remaining 171 patients, 19 had no ICD10 billing codes for their anxiety disorders, and determinations were based solely on the narrative clinical notes. The remaining 152 patients had the relevant associated billing codes, and the presence of anxiety disorders was discussed in their narrative clinical notes. There was no difference in the incidence rate of anxiety in the CP vs. AUC + CP groups, 3.4.A total of 46 patients in the whole sample had a history of IBS. All these patients also had a history of chronic pain involving different body sites, of whom 88% had reported a history of pain at multiple sites in the body. The prevalence of IBS was similar between the two groups (AUD + CP: 18% vs. CP: 19%), with no statistically significant difference between the groups. The majority of patients with IBS in both groups were women . There was a drastic difference in the incidence of IBS in patients with and without anxiety in the AUC + CP group in that IBS was about three times more common in those with anxiety in the AUC + CP group, 4.In this study, we examined the prevalence of IBS and the comorbidity of anxiety with IBS in those who only had chronic pain versus those who also had alcohol use disorders in addition to suffering from chronic pain disorders. We found that while the prevalence of IBS was not affected by the presence of AUDs in chronic pain patients, IBS had significantly higher comorbidity with anxiety disorders in chronic pain patients with comorbid alcohol use disorders. We argue that these findings highlight mechanistic differences in the comorbidity of anxiety disorders with CP and AUD and implicate a central role for GI problems stemming from chronic alcohol use that may underlie the higher comorbidity of anxiety with IBS in CP patients in the presence of AUD. In the following, we will discuss some potential mechanisms that may explain the patterns observed in this study.4.1.One potential mechanism explaining the observed patterns may be through the interference of chronic alcohol use with the proper functioning of the gut wall (through causing inflammation and chronic stress) that may affect the synthesis of serotonin, which is a critical neurotransmitter in regulating mood and emotion, among other functions via different subtypes of serotonin receptors expressed on CNS structures. In fact, altered serotonin signaling is noted in both IBS and ulcerative colitis, with decreased normal mucosal serotonin secretion . Previou4.2.Chronic and even sporadic accidental alcohol consumption is damaging to GI mucosa. In the upper GI tract, alcohol acts as a carcinogenic factor  Implica. Enteroc4.3.One potential model to explain the observed patterns could be that alcohol dries and disrupts gentle mucosal and enterochromaffin cell membranes in the gut wall and affects colonic epithelial cells’ life cycle leading to disruption of microbiota composition and functioning . As suchWhile this proposed model is simple and not comprehensive in that it does not include other possibilities , we have some preliminary data that provide some support for the proposed model: in a separate preliminary sample using medical chart data of 27 adult patients (13 women and 14 men) with a history of alcohol abuse, we found that about 70% also had a diagnosis of anxiety or depressive disorders, of whom more than half (53%) had quite low serum serotonin levels (<50 ng/ml) as determined using a similar test for all of the patients. While this sample size is small, this observation needs to be verified in a much larger sample. While the link between damage to the EC cells in the gut and anxiety in AUD may be more complex than just related to low serotonin levels, the high percentage of patients with both low serotonin levels in our preliminary sample may provide some support for our proposed model for some if not all individuals with AUDs.4.4.In this research, we primarily focused on patients with chronic pain. Chronic pain is defined as pain with a duration of greater than 3 months . There iPain could also be a reactive response of enterochromaffin cells to irritation caused by environmental or internal triggers. This occurs because enteroendocrine cells have multiple receptors expressed on their surface that enable them to react to such stimuli. One of the pathways is through the 5-HT3 serotonin subtype receptor, which can send nociceptive signals to the spinal cord . Seroton4.5.While we interpreted the patterns observed in the context of damage to serotonin-producing ECs in the GI tract, damage to other cell types may also be involved. For instance, chronic alcohol consumption may mediate mast cell activation in the gut to produce inflammatory markers that could irritate or damage other cell types, including the ECs . AdditioMoreover, mast cells may also be implicated in the pathology of IBS . HoweverFor instance, multiple studies have shown alterations in dopamine level in patients with IBS (lower level of dopamine) and dopamine plays a role in peristalsis  as well 4.6.There were some other notable patterns in our dataset. First, there were more women in the CP group (107 women versus 44 men), whereas in the AUD + CP group, there was the same number of men and women. These patterns are consistent with the prevalence patterns of chronic pain disorders that predominantly affect women and the prevalence patterns of alcohol use disorders that predominantly affect men . The dis4.7.Future studies could examine how stress affects the GI tract condition – both mucosal damage and microbiota composition in AUD and explore the mechanisms of interaction between AUD and IBS at a molecular level. Furthermore, future studies can examine how treating underlying mechanisms of GI tract conditions such as IBS may positively affect the mental health disorders such as anxiety and depression as well as chronic pain in those with AUDs.The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.KV and NM contributed to the conception and design of the study. KV performed the chart review and data extraction. NM performed the statistical analysis. KV, NM, and KJ wrote the first draft of the manuscript. All authors contributed to the manuscript revision, read, and approved the submitted version.The writing of this manuscript was supported by a grant from the National Institute on Alcohol Abuse and Alcoholism (NIAAA) K01-AA027833.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Cholecystectomy is the definite treatment for symptomatic gallstones, and rates are rapidly rising. Symptomatic complicated gallstones are generally treated with cholecystectomy, but there is no consensus on the clinical selection of patients with symptomatic uncomplicated gallstones for cholecystectomy. The aim of this review is to describe symptomatic outcomes before versus after cholecystectomy in patients with symptomatic gallstones as reported in prospective clinical studies and to discuss patient selection for cholecystectomy. Following cholecystectomy, resolution of biliary pain is high and reported for 66–100%. Dyspepsia has an intermediate resolution of 41–91% and may co-exist with biliary pain but may also develop following cholecystectomy with an increase of 150%. Diarrhea has a high increase and debuts in 14–17%. Persisting symptoms are mainly determined by preoperative dyspepsia, functional disorders, atypical pain locations, longer duration of symptoms, and poor psychological or physical health. Patient satisfaction following cholecystectomy is high and may reflect symptom alleviation or a change in symptoms. Comparison of symptomatic outcomes in available prospective clinical studies is limited by variations in preoperative symptoms, clinical presentations, and clinical management of post-cholecystectomy symptoms. When selecting patients with biliary pain only in a randomized controlled trial, 30–40% still have persisting pain. Strategies for the selection of patients with symptomatic uncomplicated gallstones based on symptoms alone are exhausted. For the development of a selection strategy, future studies should explore the impact of objective determinants for symptomatic gallstones on pain relief following cholecystectomy. Cholecystectomy is currently the only definite treatment for symptomatic gallstones. Cholecystectomy rates have been rapidly rising in European countries within the past decades ,2 and poGallstones are highly prevalent in general populations of the US and Europe and depend largely on ethnicity, age, and female sex . The natThe symptomatic complicated gallstones include acute cholecystitis, common bile duct stones, cholangitis, and pancreatitis while the uncomplicated include symptomatic gallstones in the absence of complications . CholecyEtiologies for post-cholecystectomy symptoms have recently been systematically reviewed and pooled into (1) co-existent diseases such as gastroesophageal reflux, peptic ulcer, or functional disorders; (2) physiological changes including duodenogastric reflux causing gastritis or bile acid malabsorption causing diarrhea; (3) retained or newly formed gallstones; (4) sphincter of Oddi dysfunction; (5) psychological distress; or (6) surgical complications such as common bile duct injury or incisional hernia. Symptoms may debut, but most often they persist . Common Several study limitations may bias estimates of symptomatic outcomes following cholecystectomy in published clinical studies. The risk of bias may be due to either uncontrolled estimates without preoperative symptom assessment ,25,26,27This review describes symptomatic outcomes before versus after cholecystectomy in patients with symptomatic gallstones. The focus is on declines or inclines in the proportion of patients with symptoms, on the debut of symptoms, and on the determinants of post-cholecystectomy symptoms as reported in prospective clinical studies.Symptoms of biliary pain ascribed to gallstones have traditionally been termed “biliary colic” by pioneers in medical practice such as Sir William Osler. The original symptom complex was defined by a sudden debut, of intense and agonizing pain, localized in the right hypochondrium or epigastrium, with projection to the shoulder, and a duration of hours to days or possibly even weeks . SimilarIn studies exploring gallstone prevalence in general or clinical populations, it has generally been challenging to associate gallstones with a specific symptom or complex. Although more or less strict definitions of biliary colic have been associated with gallstone prevalence when compared to controls without gallstones, the diagnostic accuracy and predictive test values are very low .Only a few determinants for the development of symptomatic gallstones have been identified when studying gallstone cohorts through long-term follow-up. In the cohort including persons uninformed and unaware of the presence of gallstones at baseline as described above, determinants for the development of symptomatic uncomplicated gallstones were pain localized in the epigastrium, with a duration of hours, of moderate to extreme intensity, and with the need for analgesics. Pain at night determined symptomatic complicated gallstones only . These fDeterminants for the development of symptomatic gallstones of a more objective character have also been identified in cohort studies. These include younger age, female sex, multiple gallstones ,51, gallThe mechanisms involved in subjective symptom generation are not fully understood but are believed to include a gallstone passage to the duodenum or an obstruction of the gallbladder or bile ducts causing biliary distention ,54. ThisMost prospective clinical studies exploring symptomatic outcomes of cholecystectomy report results from unselected patient populations including both symptomatic complicated and uncomplicated gallstones. The latter may include symptoms of unspecified pain or other abdominal complaints, such as dyspepsia. Most of these studies of unselected populations report the presence of either biliary or unspecified pain at baseline ,77,78,79The identification of underlying diseases for post-cholecystectomy symptoms requires diagnostic examinations . Most avMost of the studies reporting pooled symptom outcomes include populations with pain at baseline ,85,86,87Symptom resolution is determined by a preoperative history of cholecystitis  and a hiOutcomes for biliary colic or otherwise defined biliary pain are the most frequently reported following cholecystectomy, with a resolution of 66–100% ,78,79,97Undefined or atypical pain is estimated with a wide range of changes following cholecystectomy, from a resolution of 41–99% ,75,76,77Identified determinants for pain resolution are no heartburn, lower visual analogue scale, pain attacks , pain awDyspepsia is reported with an intermediate resolution of 41–91% ,75,95,98Definitions of dyspepsia have been without consensus and changed much throughout time. Flatulent dyspepsia was once a multi-symptomatic syndrome thought to be caused by gallstones but was also found to be due to other disorders . The morIt may be of more value to assess the single symptoms commonly thought to comprise the dyspepsia complex. Heartburn is reported to resolve for 43–72% of patients ,80,93,95In studies of populations where dyspepsia is the main complaint at baseline, a minor resolution of dyspepsia for 17–28% has been reported ,82; howeDeterminants for postoperative dyspeptic symptoms are preoperative dyspepsia ,68, non-It seems that biliary pain and dyspeptic symptoms may co-exist, and that cholecystectomy resolves dyspeptic symptoms in unselected populations where most patients report pain at baseline. However, dyspepsia may also incline or debut following cholecystectomy. Resolution of dyspeptic symptoms in populations where they are the main preoperative complaint seems inconsistent based on the currently available studies. Larger studies exploring populations with functional dyspepsia or, alternatively, analysis of subgroups should be performed in the future. Until further, cholecystectomy is not indicated for the presence of dyspepsia only.Diarrhea seems to develop rather than resolve following cholecystectomy and is reported with high inclines of 40–850% ,105,106 Diarrhea is believed to be due to continuous bile excretion following cholecystectomy, which may also cause bile acid malabsorption . AnotherEstimating the prevalence of post-cholecystectomy diarrhea is challenging. Bile acid malabsorption is diagnosed with a SeHCAT (selenium homocholic acid taurine) test that shows low absorption of radiolabelled bile acids. Tests are usually performed several years following cholecystectomy ,112. A rConstipation is reported with minor declines of 0–47% following cholecystectomy ,96,105. Abdominal bloating or distention is reported to resolve for 21–73% of patients following cholecystectomy in unselected populations ,74,76,97A recent large prospective observational study found that patients with functional dyspepsia and/or irritable bowel syndrome at baseline were significantly less likely to be pain-free six months after cholecystectomy when compared to those without (41% vs. 64%). Biliary colic was effectively resolved following cholecystectomy, independently of concomitant functional dyspepsia and/or irritable bowel syndrome . Other sCurrently, it seems that patients with mainly functional gastrointestinal disorders should be carefully selected for cholecystectomy based on the presence of biliary pain if offered surgery at all.The high rates of biliary pain resolution reported in prospective clinical studies indicate a true benefit of cholecystectomy, and it appears beneficial to select patients with biliary pain for cholecystectomy and, vice versa, refrain from surgery in its absence. A recent large randomized controlled trial, the SECURE trial, has challenged this assumption. Patients with uncomplicated gallstones and abdominal pain were selected for cholecystectomy through allocation to either a restrictive or a usual care strategy. In the usual care strategy, the selection was at the discretion of the physician. In the restrictive strategy, cholecystectomy was advised only to those patients who fulfilled a five-criteria symptom complex including (1) severe pain attacks, (2) pain duration of 15–30 min or longer, (3) pain localized in the epigastrium or right upper quadrant, (4) pain radiating to the back, and (5) a positive response to simple analgesics. If cholecystectomy was deferred accordingly at the first clinical assessment, the need was reconsidered during follow-up assessments. At one-year follow-up, only 72% versus 98% of patients allocated to the restrictive strategy were treated per protocol when compared to the usual care strategy. Thereby, a large cross-over of patients to cholecystectomy was seen in the restrictive strategy arm. The primary outcome was the proportion of patients being pain-free at follow-up, which was no different for the restrictive and usual care strategies . The only identified differences were fewer cholecystectomies in the restrictive strategy. The study concluded suboptimal pain reduction for both strategies . ParalleThe SECURE trial demonstrated the clinical challenges of withholding patients from a protocolled treatment and, even more, it challenged the definitions and predictive value of biliary pain. Despite protocolled attempts to select patients for cholecystectomy based on strict biliary pain definitions, the proportions of patients with persisting pain were unacceptably high.Patient selection for cholecystectomy relying only on patient-reported symptoms has been clinical practice for a long time but is suboptimal if the aim is a pain-free state following surgery. Although prediction scores for symptomatic outcomes of cholecystectomy are of limited availability and even fewer are validated , availabStudies exploring symptomatic outcomes following cholecystectomy mostly include heterogeneous populations with a variety of clinical gallstone presentations. Further, they fail to report a diagnostic workup or treatment for post-cholecystectomy symptoms. This challenges the comparison of symptomatic outcomes between studies. Although biliary pain seems to resolve following cholecystectomy in most patients, dyspeptic symptoms may co-exist with pain and may both resolve or develop following cholecystectomy. Patient satisfaction following cholecystectomy is high, which may reflect a symptom alleviation or, alternatively, a change in symptoms. Persisting complaints following surgery are mostly determined by preoperative functional disorders, atypical pain locations, long duration of symptoms, frequent and long pain episodes, and poor psychological or physical health. Even when the selection of patients for cholecystectomy is restricted to the presence of biliary pain, unacceptably high proportions of patients have persisting pain. Biliary pain is ill-defined and mostly based on consensus statements, but it currently remains the only criterion for cholecystectomy in the presence of symptomatic uncomplicated gallstones. The exploration of patient-reported symptoms only for the prediction of cholecystectomy symptomatic outcome has been exhausted. Future prospective clinical studies should explore the impact of objective determinants for symptomatic gallstones on pain resolution following cholecystectomy in patients with presumed symptomatic uncomplicated gallstones.


Aim: The purpose of this study is to assess the efficacy of various disinfection and hemostasis procedures in providing postoperative pain relief following pulpotomy in cases of symptomatic irreversible pulpitis.Materials and methods: The data from a cohort of 50 patients who received treatment with sodium hypochlorite (NaOCl) and another cohort of 50 patients who received treatment with potassium titanyl phosphate (KTP) laser were subjected to analysis. The patients were provided a questionnaire to evaluate pain levels before and after surgery. The patients documented their levels of postoperative pain at specific time intervals, including the sixth hour, first day, second day, third day, and eighth day. This was done using a 100 mm visual analog pain scale, where a marking of 0 mm indicated no pain and a marking of 100 mm indicated the highest level of pain, reflecting the severity of the pain experienced.Results: The pain score of group B was significantly lower than that of group A on the first day. While no notable disparity was detected among the groups during the remaining postoperative periods, it is worth noting that the KTP laser exhibited comparatively lower pain scores. In both groups, the initial pain score before surgery was found to be significantly higher than the pain scores recorded at all subsequent time intervals after surgery. Within group A, it was observed that the pain score during the sixth hour after the surgical procedure was notably greater compared to the pain scores recorded during all other time intervals following the operation. In group B, the pain score at the sixth hour exhibited a statistically significant increase compared to the pain scores observed on the third day and eighth day.Conclusion: The KTP laser group exhibited a lower postoperative pain score in comparison to the NaOCl group. The utilization of KTP laser-assisted pulpotomy demonstrated enhanced efficacy in alleviating pain among individuals diagnosed with symptomatic irreversible pulpitis. Dental caries, being a persistent infectious ailment, poses a significant worldwide public health issue. The condition of untreated caries is widely prevalent, with a global prevalence rate of 34.1%, making it a significant focus of the comprehensive "Global Burden of Disease" assessment and it continues to be the primary cause of tooth loss . AccordiThis study is based on records of patients with various permanent molars diagnosed with symptomatic irreversible pulpitis treated by pulpotomy using NaOCl or KTP laser. This study was done after taking permission from the ethical committee (MRIDS/2022/EC27).All treatment procedures were part of routine care, in which patients were verbally informed. The clinical records of a sample of 100 patients who satisfied the specified inclusion criteria were subjected to analysis. The analyzed dataset comprised various variables, namely, age, gender, presence of a percussion, tooth arch, electric pulp test, hemostasis time, presence of a periapical lesion, analgesic consumption postoperatively, and preoperative and postoperative pain scores. The selection criteria for patients undergoing pulpotomy with KTP laser and NaOCl were as follows: individuals aged 20 years or older, absence of any systemic disease, presence of a single tooth in each patient, indication of irreversible pulpitis with or without symptomatic apical periodontitis, positive response to electrical and thermal stimuli, restorability of the tooth, normal limits of probing pocket depth (3 mm), and mobility, and consistent treatment and follow-up by the same operator. The exclusion criteria encompassed the following factors: the existence of allergies, recent utilization of analgesics within the preceding 12-hour period, or administration of antibiotics within the last week prior to the procedure. The data from a cohort of 50 patients who received treatment with NaOCl and another cohort of 50 patients who received treatment with KTP laser were subjected to analysis. The selection of agents for dental application was conducted randomly.MethodologyArticaine was utilized to achieve local anesthesia. Following the application of rubber-dam isolation, the tooth crown underwent disinfection using a 5% NaOCl solution. The cavity was prepared according to the principles of cavity preparation. The removal of necrotic and infected dentin was conducted by employing an excavator and/or a round bur in a low-speed handpiece. The cavity was thoroughly cleansed using a cotton pellet that had been saturated with a 5% NaOCl solution. Subsequently, the pulp chamber was exposed by carefully removing the roof using a sterile bur. The coronal pulp tissue was extracted using a sterile round bur attached to a water-cooled high-speed handpiece. The initial hemorrhage was managed by applying a cotton pellet saturated with physiological saline. The achievement of complete hemostasis and cavity disinfection was accomplished through the utilization of either a 2.5% NaOCl solution or a KTP laser, depending on the respective experimental groups.In group A, hemostasis and cavity disinfection were done using NaOCl. In this experimental cohort, the attainment of hemostasis was accomplished through the examination of a cotton pellet saturated with a 2.5% NaOCl solution, which was positioned within the pulp chamber. The cotton pellet was assessed at two-minute intervals until the six-minute mark, and the duration of hemostasis was duly documented. In addition, the NaOCl served as the disinfectant for the cavity.Group B focuses on the application of KTP laser for hemostasis and cavity disinfection. In this study, the attainment of comprehensive hemostasis and cavity disinfection was accomplished through the utilization of a KTP laser operating at a wavelength of 532 nm. The laser was operated at a power of 1.5 W, employing both pulse and non-contact modes, with a ton of 100 ms and toff of 100 ms, for a duration of two seconds. The optical fiber possessed a diameter of 300 µm. The laser application was iterated up to three times if deemed necessary. Following the successful achievement of bleeding control, the process of cavity disinfection was carried out through the application of laser technology. The laser used had a power output of 1 watt and was equipped with a 300 µm tip. The disinfection procedure involved employing a circular motion technique in a non-contact mode for a duration of five seconds. Subsequently, calcium hydroxide was applied to the pulp orifices and the floor of the pulp chamber. The application of glass-ionomer cement was performed subsequent to the placement of calcium hydroxide. The tooth was subjected to permanent restoration using composite resin during the same session. The patients were administered a combination of 400 mg ibuprofen and 500 mg acetaminophen every six hours during the initial two-day period following surgery to manage intense postoperative pain.The patients were provided with a questionnaire to evaluate pain levels before and after surgery. The patients documented their levels of postoperative pain at specific time intervals, including the sixth hour, first day, second day, third day, and eighth day. This was done using a 100 mm visual analog pain scale, where a marking of 0 mm indicated no pain and a marking of 100 mm indicated the highest level of pain, reflecting the severity of the pain experienced.Statistical analysisThe statistical analysis was conducted using the IBM SPSS 22.0 software , which is commonly referred to as the Statistical Package for Social Sciences. The normality of the data was assessed using the Kolmogorov-Smirnov test. The statistical analysis of the data was conducted using the Mann-Whitney U, Friedman, and chi-square tests, with a significance level set at P < 0.05.Table The field of pain research has experienced a gradual increase in its significance within the realms of medical and dental sciences with pain management during both the intraoperative and postoperative phases becoming a very crucial element in the field of endodontology . DespiteThe current discourse among researchers revolves around the diagnostic nomenclature pertaining to reversible and irreversible pulpitis. The determination of irreversible pulpitis relies on clinical diagnostic procedures rather than histological findings. However, it is worth noting that these clinical diagnostic procedures may exhibit limitations in terms of reliability. The study conducted by Ricucci et al.  aimed toCalcium hydroxide is widely regarded as a highly advantageous pulp-capping agent . CalciumThe utilization of laser technology in surgical procedures is experiencing a steady rise due to its notable attributes, including prompt hemostasis, diminished risk of contamination, establishment of a sterile surgical environment, and alleviation of postoperative edema and pain . The KTPThe perception of pain is a subjective and variable experience that is influenced by both physical and psychological factors. The precise and dependable evaluation of pain holds significant importance in the realm of pain research and the implementation of effective pain management strategies. Various pain scales, such as the visual analog scale (VAS), have been employed in numerous research studies for the purpose of evaluating the intensity of pain. The VAS demonstrates satisfactory validity and reliability as a tool for assessing the intensity of pain and discomfort experienced by individuals, given that it is appropriately designed and administered .The findings of this study indicate a decrease in mean pain scores during the post-pulpotomy periods. The aforementioned findings align with results obtained from other clinical studies , which dThe KTP laser group exhibited a lower postoperative pain score in comparison to the NaOCl group. The utilization of KTP laser-assisted pulpotomy demonstrated enhanced efficacy in alleviating pain among individuals diagnosed with symptomatic irreversible pulpitis.


Lumbar facet joint pain is a common disorder. The main symptom is chronic lumbar pain, which can reduce quality of life. Radiofrequency has often been used to treat lumbar facet joint pain. However, the effectiveness of this technique has been controversial. This study was conducted to compare the effectiveness of pulsed radiofrequency (PRF) and radiofrequency denervation (RD) for lumbar facet joint pain.N = 72) and RD group (N = 70). Patients enrolled in the study were assessed using a visual analogue scale (VAS), Roland-Morris questionnaire (RMQ), Oswestry disability index (ODI) and Short-Form 36 (SF-36) questionnaire before therapy, 3 months and 12 months later.One hundred and forty-two patients with lumbar facet joint pain were allocated to two treatment groups: PRF group (p > 0.05). Significant differences in pain control were observed in both groups at 12 months . There was a significant difference in RMQ score  and ODI score  at 12 months. The total SF-36 score was higher in the RD group than in the PRF group at 12 months . In terms of complications, skin numbness occurred in three patients. Mild pain such as burning and pinking at the puncture site in two patients. One patient experienced a decrease in back muscle strength and back muscle fatigue. These complications disappeared in 3 weeks without any treatment. There were no serious adverse events in the PRF group.There were no significant differences in VAS, RMQ score, ODI score and SF-36 score at 3 months (Radiofrequency is an effective and safe treatment option for patients with lumbar facet joint pain. RD could provide good and lasting pain relief, with significant improvement in lumbar function and quality of life at long-term follow-up. Lumbar facet joint pain is a common disorder and has been attributed to substantial healthcare costs. Approximately 80% of people experience low back pain in their lifetime, and lumbar facet joint pain affects more women than men , 2. AlthRadiofrequency is a minimally invasive technique for providing lasting pain relief to patients with lumbar facet joint pain. There are two types of radiofrequency therapy, pulsed radiofrequency (PRF) and radiofrequency denervation (RD). In RRF therapy, the radiofrequency generator produces alternating repetitive electrical stimulation to keep the temperature of the nerve tissue below 42 °C . In addiThe effectiveness of radiofrequency has been well studied. Sansone et al.  reportedThis was a retrospective observational study and was conducted between October 2020 and December 2021 at the Department of Pain Management of Wuhan No.1 Hospital. In this study, 163 patients with lumbar facet joint pain were reviewed. The study was conducted in accordance with the principles of the Declaration of Helsinki and the guidelines of Wuhan No.1 Hospital. Informed consent was obtained from all individual participants included in the study. The follow-up period ended in February 2023.Inclusion criteria were: low back pain persisting for ≥ 3 months in duration; no neurological symptoms; focal tenderness over one or more facet joints; persistent low back pain, hip pain without radicular syndrome; ineffective for conservative treatment such as physiotherapy, chiropractic manipulation, exercise and medical therapy.Exclusion criteria were: neurological low back pain; age > 85 years or < 18 years; coagulopathy; infection including puncture site, lung or urinary tract; tumors, tuberculosis or severe lumbar kyphosis.n = 5), refusal to participate (n = 4), age > 85 or < 18 years (n = 9) and insufficient information (n = 3). A total of 142 patients were included in the study  and Short-Form36 (SF-36) questionnaire, respectively. Pain was assessed using the VAS, which is a reliable measure of subjective phenomena of various qualities of pain. The SF-36 questionnaire contains eight items including physical functioning (PF), role limitation physical (RP), bodily pain (BP), general health (GH), role of emotion (RE), vitality (VT) and mental health (MH). SF-36 has previously been validated for patients with chronic non-malignant pain. The Roland-Morris questionnaire (RMQ) and the Oswestry disability index questionnaire (ODI) were used to assess lumbar function. Patients were evaluated using the SF-36 questionnaire, VAS, RMQ and ODI, and administered either as clinician-administered questionnaire or as a mailed questionnaire, before therapy (baseline), and at 3 and 12 months after therapy.Although there are numerous causes of lumbar facet joint pain, compression of the posterior branches of the lumbar spinal nerves is viewed as a significant factor. Lumbar facet joint pain can be treated with radiofrequency treatment. All patients required a local nerve block to diagnose lumbar joint pain before the therapy. The patient was placed in a prone position. 0.5 ml of 2% lidocaine was injected to the posterior branch of the lumbar spinal nerve. Patients with at least a 50% reduction in VAS score measured 30 min after injection were eligible for the next step. Under the guidance of X-rays, a 22-gauge needle was advanced into the origin of the transverse and the superior articular process. On the X-ray orthopantomograph, the needle tip is situated at the junction of the outer edge of the superior articular eminence and the superior border of the transverse eminence  and GraphPad Prism software  were used for statistical analysis. Quantitative data were expressed as mean ± standard deviation. Continuous data were compared by using an independent Student’s N = 72) and the RD group (N = 70). In both groups (PRF and RD groups), the vast majority of patients were female and had bilateral low back pain. Patients in the PRF group were slightly older on average. There were no significant differences in baseline characteristics between the two groups . Remarkable differences in pain control were observed in both groups of patients at 12 months  . Although the RMQ score was high in the PRF group at 3 months after therapy, there was no statistically significant difference between the groups . Compared with the PRF group, a remarkable reduction in the RMQ score was observed in the RD group of patients, as assessed 12 months after therapy  . A significant reduction in ODI score was observed between the two groups at 12-month follow-up  . At 3-month follow-up, 139 patients were included in this study . All eight domains of the SF-36 score were almost identical in both groups (p > 0.05). Similar results were observed in the total SF-36 score between the two groups . However, at 12-month follow-up, the eight domains of the SF-36 and the total score were significantly higher in the RD group compared to the PRF group (p < 0.05)  patients in the RD group had adverse events within 1 month. Skin numbness occurred in three patients. Mild pain such as burning and pinking at the puncture site in two patients. One patient experienced a decrease in back muscle strength and back muscle fatigue. These complications disappeared in 3 weeks without any treatment. There were no serious adverse events in the PRF group.Lumbar facet joint pain is a disease that can significantly and globally impair all aspects of quality of life. Patients with lumbar facet joint pain experience moderate-to-severe pain intensity. Due to the prevalence of lumbar facet joint pain, pain control and improvement in quality of life are considered the most important outcome measures when evaluating therapeutic options.Until recently, the treatment of lumbar facet joint pain has been a challenge. Many techniques such as nonsteroidal anti-inflammatory drugs, lifestyle modifications, nerve blocks and steroid injections have been used to treat lumbar facet joint pain, but these treatments have been controversial. Radiofrequency is an effective option for lumbar facet joint pain and should be considered for patients who have not responded to conservative medical therapy. Chang et al.  have fouImportantly, the ultimate goal of treatment for lumbar facet joint pain is to improve lumbar function and enhance the quality of life. It is well known that patients with lumbar facet joint pain have a substantially impaired quality of life. A previous study reported that radiofrequency denervation of the lumbar zygapophysial joint could result in a significant reduction in functional disability in patients with lumbar facet joint pain . SimilarAs for the complications, only a few studies were designed to evaluate side effects. Duger et al.  and LakeThere is no gold standard for radiofrequency treatment in lumbar facet joint pain. The results of most studies have been inconsistent and may even be opposite –18. Our This study has several limitations. First, a major difficulty was our inability to obtain accurate scores in patients with lumbar facet joint pain. Pain, lumbar function and quality of life were assessed by description questionnaires, which are subjective measures. In the study, all the questionnaires and follow-up data were recorded by one physician and all treatments were performed by the same doctor. Second, it was a single-center study and the sample size was small. Thirdly, we did not assess the recurrence rate after the radiofrequency.In conclusion, radiofrequency is an effective and safe treatment option for patients with lumbar facet joint pain. RD could provide good and lasting pain relief, with significant improvement in lumbar function and quality of life at long-term follow-up.


The ability to control pain is an essential part of dental procedures and the need for optimal pain control and reduction of discomfort is the primary concern of every dentist. This study aims to compare the pain and vital signs during inferior alveolar nerve block between conventional and a new modification of the two-step injection techniques. U test, independent T-test, and Fisher's exact χ2 test were performed for statistical analysis (α = 0.05).  In this institutional single-blind randomized clinical trial, attendees of dental school at Mazandaran University of Medical Sciences from February to May 2022 were included. Inclusion criteria were 20–60 years old and healthy (ASA1) individuals who were willing to participate in this study. Individuals who were taking medications affecting their understanding of pain and patients with active infections at the injection site were excluded. These individuals were divided into two groups. First, superficial anesthesia was performed and afterward, conventional and two-step injection techniques were performed. For the two-step injection method, 6 mm of the needle was injected into the mucosa and one-third of the local anesthetic solution was released from the computer-controlled injection toolkit. Afterward, a 25 mm 30-gauge needle was reinserted into the previous hole delivering the remaining local anesthetic. The pain during injection was measured by a patient-reported numerical rating scale (NRS). Moreover, vital signs were monitored immediately before and after the injection. Kolmogorov–Smirnov test, Mann–Whitney  This study involved 32 adults aged between 20 and 50 years old with 1 : 1 female/male sex distribution. The pain score was significantly higher in the conventional injection technique compared to the two-step injection technique in all sex and age groups. There were no significant differences in vital signs between the conventional and two-step injection techniques. There was no significant difference in the mean pain scores of females and males, regardless of their injection techniques. IRCT20220106053646N1. Utilizing the two-step injection technique in patients for inferior alveolar block reduces pain during injection without altering patients' vital signs significantly. This trial is registered with  The ability to control pain is an essential part of dental procedures and the need for optimal pain control and reduction of discomfort is the primary concern of every dentist. Dentists throughout history have attempted to use various approaches, from alcohol to herbal remedies, to relieve patients' pain. However, the injection of local anesthetics can be a source of fear and pain and thus, patients may refuse to get injections during dental procedures or postpone their dental appointment . There aThe two-step injection techniques were proposed by Walton and Torabinejad  and LeviLimited studies have been conducted on the evaluation of the success of the two-step injection technique for anesthesia. In the studies by Park et al. , Joseph Due to the controversial findings of previous studies, it is essential to evaluate the two-step injection technique in different populations from different backgrounds and different age groups. This study aims to compare the pain level and vital signs of individuals in IANB using the conventional and a new modification of the two-step injection techniques.In this parallel single-blind randomized controlled trial, 32 individuals from all patients who attended dental school at Mazandaran University of Medical Sciences from February to May 2022 were selected. According to the sample size calculation mentioned below, the sample size of this study was calculated based on the study of Park et al. [All procedures followed were in accordance with the principles stated in the Declaration of Helsinki “Ethical Principles for Medical Research Involving Human Subjects,” adopted by the 18th World Medical Assembly, Helsinki, Finland, June 1964, and as amended most recently by the 64th World Medical Assembly, Fortaleza, Brazil, October 2013. All procedures performed in this study were approved by the Ethical Committee of Mazandaran University of Medical Sciences (#IR.MAZUMS.REC.1400.671). Patients included in this study were informed before the examination, and an informed consent form was signed by all participants. As inclusion criteria, the individuals who were 20–60 years old, healthy (ASA1), and willing to participate in this study were recruited. For standardization of the psychological condition, which can affect individuals' pain perception , the GenThe patients were seated on the dental unit for 10 min to restore heart rate and blood pressure to normal levels . The patA 25 mm 30-gauge needle  was used for conventional IANB injection. Moreover, a computer-controlled injection toolkit  was utilized for injecting at different speeds . The needle was inserted into the tissue by using the computer-controlled injection toolkit with the highest speed (50 s for injecting 1.8 ml of anesthetic solution). During the penetration of the needle, 0.4 ml of 2% lidocaine with 1 : 80,000 epinephrine anesthetic solution  was injected. The rest of the anesthetic solution (1.4 ml) was injected after the needle reached the mandibular bone in 1 min.In this modification of the two-step injection technique, the first step of injection was operated by using a 12 mm 30-gauge dental needles  at the lowest speed of the computer-controlled injection toolkit (250 s/1.8 ml). Because the topical anesthetic gel, which was applied before, had affected the 5 mm depth of soft tissue , 5 mm ofAfter waiting for 2 min, the second needle was used, which had the same properties as the needle used for the conventional technique. The entire length of a 25 mm 30-gauge needle was reinserted into the previous short needle penetration hole at the highest speed (50 s/1.8 ml) moving to the desired area for delivering the remaining local anesthetic solution (1.2 ml) .Before, during, and after the injection, patients' vital signs, including the heart rate, blood pressure, and respiratory rate, were monitored and recorded in both groups by using a vital sign monitor  that was attached to the patients. These injection procedures were performed by an oral and maxillofacial surgeon with 10 years of experience. Afterward, the participants reported their pain during the injection by employing a numerical rating scale (NRS) from 0 to 10 (from 0 which indicates no pain to 10 which indicates the worst pain possible).Because of the procedure of intervention during this study, it was not possible to make the patients and operators blind due to observing the use of a second needle. Therefore, the blinding was only applied to statistical analysis.U test, independent t-test, and Fisher's exact χ2 test were performed for statistical analysis by SPSS 22 . p-Value <0.05 was considered as statistically significant.Kolmogorov–Smirnov test, Mann–Whitney p > 0.05).Thirty-two individuals participated in this study . The demographic information of the individuals is shown in t-test showed that pain scores were significantly higher in the conventional method compared to the two-step injection technique  (Utilizing an independent  <0.001) .There was no significant relationship between pain score and vital signs and demographic variables. However, the pain score was significantly higher in conventional techniques in all sexes, age ranges, and education levels .This study investigated the self-reported pain scores and vital signs of individuals during IANB using a new modification of two-step and conventional injection techniques. The findings demonstrated that the individuals who received the conventional technique for injection experienced more pain compared to those with the two-step injection technique. In addition, the pain scores of all sex and age ranges were significantly higher in the conventional injection technique compared to the two-step injection technique. Moreover, monitoring participants' vital signs showed that there were no significant differences between individuals' vital signs before and after injection in both groups.According to the findings of this study, the pain scores and vital signs were not significantly different between males and females, regardless of their injection techniques.In clinical dentistry, local anesthesia is a unique combination of methodology, anesthetic substances combination, and equipment. Pain and fear during dental routine treatments and surgeries are among the most important reasons for avoiding dental procedures among patients . MoreoveThe findings of this study were in agreement with the studies by Park et al. , Joseph Because of this controversy regarding the result of reducing pain by using two-step injection techniques in the abovementioned studies, we developed a new modification of the two-step injection technique. In this new modification, we tried to reduce pain compared to the two-step injection techniques that had been used in other studies by considering effective properties such as injection speed and needle length. Penetration of the needle into the oral mucosa is the first phase of the pain experience during anesthetic injections for dental and oral treatments. Previous analysis of pain perception at the needle penetration stage showed a 14%–22% incidence of moderate to severe pain ; therefoIn addition, the results of this study showed that in both sexes, there was a significant difference between the pain score of conventional and the two-step injection techniques and that the pain score was reduced during the two-step injection technique. Similar to our findings, a study by Park et al.  demonstrThe results of this study also showed that none of the vital signs showed significant differences in the two groups of conventional and two-step injection techniques. Moaddabi et al.  showed tThe limitation of this study was the lack of the possibility of patients and operators blinding. Furthermore, another limitation of this study was the patient's lack of cooperation. Moreover, utilizing this technique can cause extra costs for patients and dentists due to using multiple needles and a computer-controlled injection toolkit.Utilizing the new modification of the two-step injection technique in patients for IANB reduces pain during injection, which is not related to sex and age and does not change the patient's vital signs significantly.


We set out to investigate whether anterior knee pain following anterior cruciate ligament reconstruction has a significant effect on patients, and whether it should influence graft choice.This was a qualitative analysis of a set of recreational athletes treated at a university hospital at about 1 year following anterior cruciate ligament reconstruction surgery. Participants were interviewed by an orthopaedic fellow and resident using structured, open-ended questions. Inductive theme analysis was used to code the data.There were 4 major themes: (1) Our hypothesis was that patients would be given adequate information to make an appropriate graft choice. This hypothesis was rejected. Discussion took place, but with little details or rationale for the graft choice. The predominant theme was that the surgeon made the decision, and there was a lack of reliable information for the patient to make a choice. (2) The overall theme was that most patients had no anterior knee pain, and it did not interfere with activities of daily living. (3) One theme was that patients were able to resume all sports without restriction, but in some, the anterior knee pain interfered with the more demanding activities such as impact, cutting, and pivoting. A separate theme was that fear was a major impediment to return to sports and was not related to the anterior knee pain. (4) The overriding theme was that the generalized closures associated with the COVID-19 pandemic slowed the rehabilitation process. Although virtual care was available in general, it was not particularly satisfactory. Patients indicated that they had not been able to return to the gym or to their sporting activities as a result.Amongst non-competitive athletes, anterior knee pain post-anterior cruciate ligament reconstruction surgery does not significantly affect activities of daily living. Although there is a minor effect on sporting activities, the inability to return to sports is related to factors such as the COVID-19 pandemic, fear, or insufficient rehabilitation, rather than anterior knee pain. Overall, anterior knee pain is not a significant factor that plays a role in determining graft choice.The online version contains supplementary material available at 10.1186/s13102-023-00630-6. Anterior knee pain after anterior cruciate ligament (ACL) reconstruction is a common symptom, especially when a bone tendon bone (BTB) graft is used , 13, 16.As a secondary effect, because the study was carried out during COVID-19 when local public health guidelines required virtual physician and physiotherapy visits, we were also able to determine the effect the pandemic had on rehabilitation and outcome from a patient perspective , 15.The aim of this study is to determine whether anterior knee pain post-ACL reconstruction surgery significantly affects patients, and whether it should influence graft choice. A qualitative design was used to collect and analyze data. This methodology allowed us to assess patients’ experiences and perspectives in a way that quantitative research otherwise could not answer . The stuThere was a total of 35 patients with 17 patella tendon autografts, 9 hamstring autografts, and 9 quadriceps tendon autografts. There were 20 males and 15 females. The age range was 21 to 47 years . The goal was to recruit and interview participants until we reached the point of data saturation, which occurred after the 35th participant was interviewed. Further interviews were no longer required as no new data and themes were being found . The 10–Transcripts were then uploaded to Quirkos  – a software used for qualitative examination of textual data – and were assessed using inductive theme analysis. Themes and codes were shaped by and derived from the raw text data . Codes wI think he just mentioned the hamstring and we went with that. He explained the other ones but for me it was just straight forward on the hamstring graft.—Subject 1The hamstring was presented as the option, but it wasn’t presented as a list of options.—Subject 6No, I think he may have told me what graft we will be doing but never talked about the options.—Subject 9Our hypothesis was that patients would be given adequate information to make an appropriate graft choice. The general theme is that discussion took place, but with little details or rationale for the graft choice. The predominant theme was that the surgeon made the decision. Patients felt there was little information available to them to help make an informed decision. There was no difference within the gender groups of male or female, or within the groups depending on the graft type .OK, with my doctor, in our consultation, we talked about what I did for living and he is more of an expert in sports medicine, I mean they're fairly parallel, but he is more of a hockey guy, so he got on the phone with his friend who is more of a dance surgery specialist and ask for his recommendation—Subject 2.There wasn't that many resources available, but I also tried to look at like academic papers to see if there is any info about the recovery time—Subject 4We mostly talked about quadriceps tendon, and patellar tendon I believe. The surgeon recommended the quadriceps tendon as one he has had success within athletes. So, I took that information and did my own research and found there is reasonable success with both options of grafts, so I was happy to go with the surgeons’ recommendation.—Subject 12.The second interesting theme was that patients did a lot of research themselves. Graft choices were offered based on what their social network groups thought was advisable. Patients noted that there was little in the way of clear guidance available to them.At this point I wouldn't say that it's affecting my quality of life at all—Subject 3I am happy with the outcome, doing most of the stuff with no issue—Subject 6I'm able to do everything I want to do. I can run and I have been working up to doing some jumping—Subject 13The overall theme was that patients had little or no pain and it did not interfere with activities of daily living. They stated that they could do everything that was required, although there were some patients who were symptomatic. As such, the different graft options would make no difference in terms of patients’ activities of daily living.When I'm squatting, some cracking in the knee like there's something that is breaking but it is just the sound, no pain, no discomfort—Subject 1Stairs are fine, kneeling is not painful but weird because of numbness—Subject 3No difficulty, but I can feel more pressure when I am kneeling down—Subject 5However, we noted different themes depending on the graft type. Patients with hamstring repairs had vague symptoms of pain around the knee, but no specific limitations.The only time that I get any real pain is in full extension, like trying to press my knee into the ground. it's not like an incredible amount of pain but it's definitely noticeable in terms of doing daily exercises or doing pretty much anything on a day-to-day basis—Subject 3.I never notice it but when I specifically go out of my way to extend my knee as much as possible, I will get some stiffness.—Subject 3It's in the front, right where the surgical area was, basically on a line below my kneecap right in the front—Subject 3Patients with bone tendon bone repairs had specific issues with kneeling and stairs and had difficulty with full extension of the knee. Although they had the symptoms, it did not interfere with any of their activities of daily living. This group of patients also had a specific issue with numbness around the scar.If I'm sitting for too long then my knee feels stiff, but I think that's pretty normal—Subject 4It’s like a pain that is constantly there. But it fades away after a few minutes. It is not a sharp pain, occasionally it is sharp, but it does not stay there.—Subject 8Every now and then, it is not 100%, I’d say, it’s a little creaky. Pain is right in the gap, just right of the kneecap (left knee).—Subject 10Those with quadriceps tendon grafts had issues with muscle stiffness and symptoms from the graft site in the quadriceps, but did not have any specific issues with kneeling or stairs, or any limitations in their activities of daily living.Within this set of interviews there were 3 major themes.I'm able to do everything I was able to do before the surgery and before the injury too—Subject 1Not sure I'd be quite as good as I was before, but I think good in the long run. I don't expect any issues—Subject 3In my view it was a raging success all the way across the board—Subject 7In the first theme, patients were able to return to all their pre-injury activities. Any residual knee pain was minimal and did not limit them. This group of patients were particularly satisfied with the procedure. There were no noticeable differences in the graft types or sex of the patient.It has, but only because I am aware that my knee is not 100% strong, and it doesn’t have the confidence that the leg is ready for it. I would say that it has just reduced the fun factor—Subject 11.Unable to take longer walks, limited to 4–5 km, can still bike, cannot play with kids, and own physical health as a result of pain—Subject 14I can’t do running/sprinting and long hikes with elevation. Do not trust knee yet for explosive activities. I feels as though I need to continue strengthening. Unable to kick a ball…too much impact—Subject 15.In patients who had not returned to their pre-injury level of sports, the predominant issue was the lack of strength. Only occasionally did patients mention that the knee pain itself was a factor despite this being a specific question. In other words, our research would indicate that the anterior knee pain was not a significant factor in limiting sporting activities. It was a factor in limiting activities such as kneeling directly on the patella and in using stairs, but not in limitations of activity.I am able to do everything else … I can run and I have been working up to doing some jumping but I'm just really scared—Subject 2Mental health aspect, thinking about future; will it get better or worse, will it progress, other surgeries needed?—Subject 14The third major theme was the fear of reinjury. This has been reported by other authors as a significant factor in failure to return to sports. Specifically, the fear of reinjury did not seem to be related to the anterior knee pain. There was, however, a significant concern regarding a lack of psychological assistance in recovery and return to sports.Rehab it took a little longer because of COVID, so I'm still working on the muscle gain—Subject 1I guess that (my fear) also could have been abated if we had had more follow up, but the pandemic happened, so all our follow-ups were few and far between—Subject 2I can do everything that I want to do. However, given this COVID situation I'm not really trying to go play soccer—Subject 4The recovery has been a long difficult time. For one reason, during the pandemic, I wasn’t going to the therapist as much as I would like, and the gym was closed. For a few months after surgery, I did some virtual therapy, but it wasn’t the same—Subject 5.Subject 7As a result of COVID, my physio appointments were quickly cancelled at probably just the wrong time—Squatting is bothersome as well. But I haven’t necessarily done the appropriate strength training because of COVID, not able to go to physio or the gym and stuff—Subject 10Thereafter the pandemic hit, so I basically did not go and see a physiotherapist. So, I know for certain that I did not have a chance to re-train the muscles that I would have otherwise—Subject 11.The overriding theme was that the societal response to the pandemic with generalized closures slowed the rehabilitation. Although virtual care was available, it was not particularly satisfactory. Patients indicated that they had not been able to return to the gym or to their sporting activities as a result. Patients stated that they had not fully tested the knee in the usual recreational activities because of the unavailability of gyms or sporting programs. It does not appear from the interviews as though anterior knee pain was a significant factor in affecting recovery during the pandemic.It’s extremely debilitating. Any sort of physical activity I do now revolves around making adjustments to prevent the pain from happening. It is also the focus on physiotherapy to make it better. There is also a ton of activities and sports that I avoid in order to not make it worse—Subject 9.I feel like there was a communication breakdown early on after surgery that set me off on a path to a poor recovery. Going into surgery I was naïve about how important physiotherapy was in your recovery—Subject 9.There was one patient who had a particularly poor outcome. From the patient’s perspective, the recovery was long and arduous. It was useful to have this patient in the group as we felt this did indicate saturation with at least one unsatisfactory result.We set out to investigate whether anterior knee pain following ACL reconstruction significantly affected a patient’s activities. Our hypothesis was that the presence of anterior knee pain would represent a significant impairment that would ultimately affect graft choice, and that interference with activities would be a major theme. This hypothesis was rejected.Studies have shown that patients with ACL reconstruction often have anterior knee pain , 9, 16. We found that although anterior knee pain was present as a theme, it did not significantly affect the patients’ quality of life or activities of daily living. Anterior knee pain, which affected high demand activities, was a minor theme in terms of sports. The major theme was that although there may have been some pain and discomfort, it was not a limiting factor. We did not expect this outcome based on review of the current medical literature and generally held beliefs.The type of graft did not seem to affect the presence, absence, or effect of anterior knee pain. The theme of some residual difficulties was present with all three graft types. This implies that the presence or absence of anterior knee pain would not be a significant factor in graft choice.We had hypothesized that patients would be given sufficient information for a fully informed consent, and that this would include an adverse outcome associated with anterior knee pain. This hypothesis was rejected. Based on our analysis, a more detailed description of the rationale for graft choice, as well as the rehabilitation procedures, would be beneficial. There was little or no discussion regarding anterior knee pain following the ACL reconstruction and how this would affect the patient’s activities. There is a generally held belief that choice is an important part of provision of healthcare. This includes such concepts as patient-centered care, shared decision-making, and informed choice . Within A major issue was the lack of mental preparedness for the ACL surgery and rehabilitation. Many participants expressed that it was fear in particular that was keeping them from achieving their true potential in the post-operative period. Specifically, the fear of reinjury held patients back from returning to sports and attaining the same level of activity they had prior to their injury. The patients felt that although there would be significant value to seeking psychological help, this was not readily available. This may be a fruitful area for educational upgrading by rehabilitation providers , 15.The COVID-19 pandemic affected patients’ access to rehabilitation and return to sports . There cPatients in this study were part of a general population presenting at a Canadian university teaching hospital. They were recreational athletes, thus making our study valid for the general population. These results may not apply to professional athletes who have significantly more access to resources than the general population. The results therefore will be particularly useful to the general orthopaedic surgeon, rather than those with clinical practices with more elite athletes.In the general population of recreational athletes, residual anterior knee pain following ACL reconstruction does not have a significant effect on activities of daily living. The effect on sporting activities is relatively minor, and the inability to return to sports is more related to other factors such as fear of reinjury or inadequate rehabilitation rather than the anterior knee pain. As such, anterior knee pain is not a significant factor in determining the type of graft.Patients had poor availability of information to make appropriate choices for graft type. This needs to be addressed by various academic organizations.The COVID-19 pandemic affected patients’ rehabilitation due to a lack of availability of resources. It has also affected patients’ ability to return to their pre-injury sporting activities and thoroughly test the reconstruction.Additional file 1. Transcripts of the qualitative interviews that took place 9-15 months post anterior cruciate ligament reconstruction surgery. The interviews, which were conducted by an orthopaedic fellow and resident, consisted of structured, open-ended questions that aimed to evaluate how postoperative anterior knee pain affected different areas of the patient's life.