Preliminary evidence suggests that psychological trauma, especially childhood trauma, is a risk factor for the onset of fibromyalgia (FM).  The main objective of this study consisted of evaluating the prevalence and detailed characteristics of psychological trauma in a sample of patients with FM, the chronology of trauma across the lifespan, and its clinical symptoms. We also calculated whether childhood trauma could predict the relationship with different clinical variables.  Eighty-eight females underwent an interview to assess sociodemographic data, psychiatric comorbidities, level of pain, FM impact, clinical symptoms of anxiety, depression, insomnia, quality of life, and psychological trauma.  The majority of participants (71.5%) met the diagnostic criteria for current post-traumatic stress disorder (PTSD). Participants reported having suffered traumatic events throughout their lifespan, especially in childhood and early adolescence, in the form of emotional abuse, emotional neglect, sexual abuse, and physical abuse. Traumatic events predict both poor quality of life and a level of pain in adulthood. All patients showed clinically relevant levels of anxiety, depression, insomnia, suicidal thoughts, and pain, as well as somatic comorbidities and poor quality of life. Pain levels predicted anxiety, depression, dissociation, and insomnia symptoms. 84% of the sample suffered one or more traumatic events prior to the onset of pain. Trial registration: ClinicalTrials.gov NCT04476316. Registered on July 20th, 2020. Our data highlight the clinical complexity of patients with FM and the role of childhood trauma in the onset and maintenance of FM, as well as the high comorbidity between anxiety, depression, somatic symptoms, and FM. Our data also supports FM patients experiencing further retraumatization as they age, with an extremely high prevalence of current PTSD in our sample. These findings underscore the need for multidisciplinary programs for FM patients to address their physical pain and their psychiatric and somatic conditions, pay special attention to the assessment of psychological trauma, and provide trauma-focused interventions.  Fibromyalgia (FM) is considered the second most common rheumatic disorder  and affeDespite all the studies that highlight the relationship between childhood trauma and FM, few studies have collected in detail the chronology of the traumatic events to which these patients are exposed throughout their lifespan, from infancy to adulthood, as well as information on whether these events occurred mainly before or after the onset of pain. Likewise, many studies have focused on studying the correlation between trauma and pain. However, there is a lack of studies on possible predictor variables that explain the relationship between childhood trauma, pain, and the presence of psychiatric comorbidities, which are highly prevalent in this population and significantly affect the functionality and quality of life of the patients.Our study aimed to analyze the prevalence and clinical characterization of traumatic events present in women with a principal diagnosis of FM and to what extent these events can predict pain levels, the presence and intensity of affective symptoms, psychiatric comorbidity, insomnia, and quality of life.n = 42) and from the adult mental health services (n = 30) of the Parc de Salut Mar in Barcelona, Spain. Further participants (n = 18) from the catchment area learnt about the study through word of mouth or from local FM associations and contacted researchers to voluntarily enroll. The study was conducted between January 2020 and January 2021. All women were evaluated through an individual clinical interview that lasted approximately 1.5 hours and was conducted by two psychologists from the forum center research unit. In some cases, the assessments were carried out in person, but when participants were not able to attend the interviews because of COVID-19-related restrictions, clinical evaluations were carried out online.The study sample consisted of 90 female participants diagnosed with FM, who were consecutively derived from the rheumatology service (Participants had to fulfill the following inclusion criteria: (1) women with an FM diagnosis based on a clinical interview aligned with the American college of rheumatology criteria , and (2)The investigation was developed in accordance with the latest version of the Helsinki Declaration and was approved by the ethics committee “Comité Ético de Investigación Clínica del Parc de Salut Mar” (reference number: 2020/9158). All participants gave written informed consent following a full explanation of the study before enrolling.In the clinical interview, the evaluators gathered the data following a previously designed case report form (CRF) for the study. The CRF collected sociodemographic variables such as age, race, educational level, marital status, employment status, psychiatric and somatic comorbidities, and pharmacological treatment. A series of validated scales were also administered for the evaluation of pain and FM impact, psychological trauma and associated symptoms, comorbid psychiatric disorders, clinical symptoms of depression and anxiety, insomnia, and quality of life. The scales are detailed as follows:Visual analog scale (VAS) for pain : This scPain disability index (PDI) : This scFibromyalgia impact questionnaire , SpanishChronology of traumatic events: This tool consists of a table, which gathers all the traumatic events reported by the participants over their lifespan according to their age when each occurred. The table is divided into five-year segments spanning from 0–5 up to 65–70 years. For each segment, participants are asked, “Do you remember having any traumatic or stressful experiences when you were in this age group?”. Answers are then coded using thematic analysis. Traumatic events were then subsequently categorized as one of the following: emotional abuse; physical abuse; sexual abuse; emotional neglect; physical neglect; parental violence; drug abuse by a family member; parental mental disorder; parental mental disorder; accident; physical violence in adulthood; rape, abuse or sexual attack; harassment or psychological maltreatment in adulthood; death of a loved one; abortion; surgery; imprisonment, detention, or kidnapping; illness of a first-degree relative; personal illness; pregnancy itself or pregnancy complications; personal separation or divorce; mobbing; economic problems; familiar conflicts; others , or no traumatic event.Global assessment of post-traumatic stress questionnaire (EGEP-5) : This 55Subjective unit of distress (SUD) : this scHolmes and Rahe social readjustment scale , SpanishChildhood trauma questionnaire (CTQ) , SpanishDissociative experiences scale (DES) , SpanishSomatoform dissociation scale-20 (SDQ-20) , SpanishFM diagnosis: FM diagnosis based on a clinical interview aligned with the American college of rheumatology criteria , which wPsychiatric comorbidities: MINI neuropsychiatric international interview , SpanishHospital anxiety and depression scale (HADS) , SpanishAthens insomnia scale (AIS) , SpanishSatisfaction with life scale (SWLS) , SpanishR = 0.30) with 80% statistical power is 84. However, researchers decided to include all candidates who were recruited between January 2020 and January 2021 who signed the informed consent and met inclusion criteria, even if the calculated number was exceeded.Given that the main objective of this study was to investigate the relationship between childhood trauma (CTQ) and FM pain (VAS pain), we calculated the sample size needed to conduct a regression analysis between CTQ and VAS pain. According to the standard formula, the sample size required to detect small correlations . Fitness to parametric assumptions was checked for all variables. To assess the normality of data distribution, the Shapiro–Wilk test was used.First, regarding the descriptive analysis of the sociodemographic, medical, and clinical data Tables  and 2, tSecond, simple linear regression has been used to analyze whether different types of child maltreatment (CTQ measures) could predict different clinical variables, namely anxiety and depression.Third, we also used the simple linear regression model to analyze whether the scores obtained on the fibromyalgia pain and impact scales  could predict the clinical variables discussed above (HADS and AIS) and the patients' quality of life (SWLQ).n = 31, 35.2%), unemployed , or unable to work due to mental health problems or other problems   see .Regarding the medical data of the sample, other comorbid axis III diagnoses were common, with the most prevalent being chronic fatigue syndrome (60.2%), followed by osteoarthritis (30.6%). Participants were prescribed various pharmacological drugs, with the most frequent being anxiolytics/hypnotics (60.9%); then, serotonin-norepinephrine reuptake inhibitors (SNRIs) (49.4%), paracetamol (36.7%), opioids  and anti-inflammatory drugs (35.2%) see .According to the MINI, anxiety disorders  and mood disorders (76.1% for major depressive disorder and 11.3% for dysthymia) were the most frequent psychiatric comorbidities. These results were confirmed by higher current scores in the HADS . Participants showed marked scores in the AIS  suggestive of sleep disturbances and an important degree of dissatisfaction with their lives according to the SWLS scores . In terms of suicidal behavior, 82.9% of the participants reported having had thoughts of suicide at some point in their lives, and 32.9% had carried out at least one suicide attempt in their lifetime, of which 4.5% used violent methods  and 27.2% nonviolent methods (e.g. drug over-ingest), 13.6% suffered severe consequences , and 18.18% nonsevere consequences  see .M = 35.44, SD = 11.93; FM diagnosis: M = 44.55, SD = 8.50) . Furthermore, we also found a marked degree of disability  with a generally large negative impact of FM on daily functioning and quality of life . The average number of years between the onset of pain and the diagnosis of FM in the sample was 9.10 (onset of pain: .50) see .The EGEP-5 scores revealed that 71.5% of the participants met the criteria for PTSD in the last month. In relation to the event chosen by each participant for the administration of this scale, 34 women selected an event that occurred in their childhood, 47 an event that occurred in adulthood, and this data was missing for 7 participants. The average score of subjective distress, measured via SUD, was 8.23 , indicating great psychological distress in relation to that event see . Total DOur FM sample experienced low-to-moderate levels of all types of child maltreatment in the CTQ, with both emotional abuse (63.6%) and emotional neglect (62.5%) being the most frequent maltreatment, followed by sexual abuse (48.8%), physical neglect (40.9%), and physical abuse (31.8%). Of note, minimization and denial in the CTQ were controlled for. Furthermore, patients showed an average of 7.64 (SD = 0.42) stressful events that happened during the last year and a high total score on the Holmes and Rahe scale , which is suggestive of a 50% risk of developing stress-related disorders see .n = 39), sexual abuse (n = 32), and emotional abuse (n = 29) (see n = 71), followed by harassment or psychological abuse in adulthood (n = 57), and other experiences grouped in the category “other traumatic events” (n = 39)  see , while t 39) see . InteresF  = 6.30; p = 0.0140), emotional neglect  = 12.94; p = 0.0005), and physical neglect  = 6.10; p = 0.0155) predicted low quality of life (high scores on the SWLS) in our sample. The same was true for the total score obtained on the CTQ  = 8.27; p = 0.0051) and two measures of pain, the PDI and S-FIQ  = 8.69; p = 0.0041 and F  = 8.08; p = 0.0056), respectively.All linear regression results can be gathered from F  = 4.12; p = 0.0455).In addition, linear regression analysis also showed that higher scores in physical neglect significantly predicted higher levels of pain in the VAS  = 3.99; p = 0.0489) and anxious  = 10.08; p = 0.0021) symptomatology, which was also true for the PDI  = 31.14; p = 0.0000); HADS-A: F  = 22.58; p = 0.0000) and S-FIQ scales  = 12.39; p = 0.0007); HADS-A: F  = 27.16; p = 0.0000).On the other hand, linear regression showed that higher scores in the pain measures and FM impact on quality of life  significantly predicted the presence and intensity of depressive and anxious symptomatology. More specifically, the VAS significantly predicted both depressive  = 4.31; p = 0,0410) and the scores obtained in dissociation  = 4.30; p = 0.0412). The PDI significantly predicted the total score  = 10.50; p = 0.0017) and the scores obtained in amnesia  = 6.27; p = 0.0142), depersonalization  = 6.29; p = 0.0140), and dissociation  = 7.56; p = 0.0073) subscales. The same was true for the S-FIQ  = 11.83; p = 0.0000), DES-A: F  = 8.61; p = 0.0043), DES-DP: F  = 5.08; p = 0.0268), DES-D: F  = 10.25; p = 0.0019).Likewise, the scores in the pain and in the FM impact  also significantly predicted the degree of dissociative experiences (DES). VAS significantly predicted both the total score  = 19.18; p = 0.0000; F  = 8.94; p = 0.0036; and F  = 7.69; p = 0.0068, respectively).Furthermore, linear regression analysis was also suggestive that patient scores on pain and FM impact  also significantly predicted sleep disturbance  was selected for the administration of the EGEP-5, an event that occurred in childhood that was the most significant traumatic event in their lives. These data, therefore, once again highlight the strong and enduring impact that childhood trauma can have on health in adulthood. Our data not only reaffirm the existence of high comorbidity between PTSD and FM but also confirm that individuals with comorbid pain and PTSD report greater pain, PTSD symptoms, depression, anxiety, disability, and opioid use than people who only have one of these conditions [To the best of our knowledge, this is one of the few studies that has assessed the characteristics of the traumatic events suffered by a sample of women with FM in a systematic and chronological way. The results have shown that the most prevalent traumatic events categorized by age occurred during childhood and adolescence, especially in the form of physical abuse, sexual abuse, and emotional abuse, but have continued into adulthood, modifying their typology and presenting themselves mainly in the form of deaths of loved ones, harassment and physical abuse, rape, abuse, or sexual assault. These data are clinically relevant as they suggest that female FM patients are chronically and recurrently exposed to different types of stressful or vital events throughout their lives, favoring the appearance of a process of continuous retraumatization that would explain the very high percentage of PTSD diagnoses in our sample. In fact, 100% of the participants reported having suffered at least one major traumatic event at some point in their lives, and 84% had suffered one or more types of these traumatic events prior to the onset of pain. Likewise, 71.5% of the whole sample met the criteria for current PTSD, adding a further comorbidity in this complex population. These data are far higher than the prevalence data found in the general population, which range from 0.2% to 3.8% , and alsnditions .Regarding the results of the CTQ, our participants presented low to moderate levels of all types of childhood maltreatment, especially emotional abuse and emotional neglect, followed by sexual abuse, physical neglect, and physical abuse. These results are in line with other studies which compared FM patients to controls or patients with other pain conditions, where they found higher CTQ scores in the FM group, with emotional abuse and neglect representing the most frequent subtypes , 58–60. According to the Holmes and Rahe social readjustment scale, we found a high prevalence of major stressors that happened over the last year, compounding the prior presence of trauma-related stress and increasing its negative impact on participants' well-being. In fact, people with FM suffer from more major life stressors than patients with migraine , rheumatAlthough our results showed that scores on pain scales predicted the occurrence of dissociation, participants showed generally low dissociation scores on the DES scale, with the exception of the dissociation subscale, where our patients scored highly. The general low scores in dissociation are surprising, taking into account the aforementioned trauma load and high prevalence of PTSD in our sample, and also considering that dissociation is a very common phenomenon in people suffering from PTSD. A possible explanation for this could be that psychotropic medication improves dissociative symptoms by exerting an inhibitory effect on the central nervous system. However, this hypothesis needs further data because pharmacological studies available in this field are scarce and inconclusive . AnotherAdditionally, we detected a very high prevalence of psychiatric comorbidities such as generalized anxiety disorder (87.5%), major depressive disorder (76.13%), and panic disorder (63.6%), and a lower but still important prevalence of social phobia/agoraphobia (29.5%), followed by dysthymia (11.3%), and finally obsessive-compulsive disorder (3.4%). This underlines the complexity and multidiagnostic nature of FM patients and is in line with previous literature, which reports that psychiatric comorbidity among FM, anxiety, and mood disorders is common and is a factor that can complicate medical prognosis ,75. Of nOur results not only confirm the high anxiety and depression scores in our sample but also that the scores obtained by the participants in the pain and fibromyalgia scales  significantly predict the presence and intensity of depressive and anxious symptomatology. This bidirectionality has been reported in previous literature showing that mental disorders, such as depression or anxiety, can be a consequence of living with chronic pain , as wellOf note, 82.9% of the participants in the present study reported suicidal ideation in their history, while 32.9% reported suicide attempts. These data confirm the high prevalence of suicidal behaviors in patients suffering from chronic pain compared to the general population –81. TherFinally, our sociodemographic characteristics provide insight into the high co-occurrence of various axis III diagnoses, including CFS (60.2%), confirming the overlap between both diagnoses ,89, osteSeveral limitations have to be considered when translating our results into clinical reality. The first limitation is that we did not include a matched control group to compare our results with those of the FM group, which needs to be taken into account when interpreting and generalizing our results. Second, we did not control for possible psychiatric drug effects that could be interfering with the clinical manifestations reported by the participants. Third, the sample comprised solely female participants, so we do not know whether these results can be extrapolated to the male population. However, previous data shows that mainly female patients are affected by FM . Fourth,The strengths of our work included the exhaustive evaluation of psychosocial and clinical data; a detailed evaluation of psychological trauma and its impact on participants by using validated psychometric tools; and a detailed knowledge of the chronology of traumatic events, allowing us to sequence the appearance of pain in their lives. Furthermore, the homogeneity between raters has helped to obtain data, reducing observational bias.Our data highlight the complex comorbidity of FM patients with somatic disorders, psychiatric disorders, such as anxiety, depression and PTSD, highly prevalent suicidal behavior, and sleep alterations. Patients with FM, who are usually treated by rheumatologists, receive multiple psychotropic and analgesic medications, with often unsatisfactory results . Our dat


Juvenile Idiopathic Arthritis (JIA) is a childhood-rheumatic disease with pain as a major early complaint, and in 10–17% pain remains a major symptom. Very few data exist on sensory threshold changes at the knee in JIA, a location in which inflammation often manifests. We determined whether JIA is associated with sensory threshold changes at the knee by using Quantitative Sensory Testing (QST) and established reference values at the knee of children.Sixteen patients with JIA aged 9–18 years with one affected knee and a patient-reported pain by Visual Analog Scale (VAS) > 10 on a 0–100 scale, and 16 healthy controls completed the study and were included for the analysis. QST was assessed in compliance with the German Research Network on Neuropathic Pain (DFNS) standard. Disease severity was determined using Juvenile Disease Activity Score . Feasibility of QST was tested in patients aged 6–9.Under the age of 9, QST testing showed not to be feasible in 3 out of 5 JIA patients. Patients with JIA aged 9 and older reported an average VAS pain score of 54.3. QST identified a significant reduction in pressure pain threshold (PPT) and increase in cold detection threshold (CDT) compared to healthy controls. PPT is reduced in both the affected and the unaffected knee, CDT is reduced in the unaffected knee, not the affected knee.In a Dutch cohort of Patients with JIA, QST is only feasible from 9 years and up. Also, sensory threshold changes at the knee are restricted to pressure pain and cold detection thresholds in Patients with JIA.This article shows that in a Dutch population, the extensive QST protocol is only feasible in the age group from 9 years and older, and a reduced set of QST tests containing at least pressure pain thresholds and cold detection thresholds could prove to be better suited to the pediatric setting with arthritis.The online version contains supplementary material available at 10.1186/s12969-022-00715-5. Juvenile idiopathic arthritis (JIA) is the most common childhood rheumatic disease . JIA is Quantitative Sensory Testing (QST) is a reliable methodology to objectively and accurately assess changes in sensory functioning beyond that of self-reported pain assessments. This technique enables measurement of sensory sensitivities, including that for pain and different sensory modalities . A validIn this study, we tested an extensive set of sensory modalities in the knees of Dutch Patients with JIA to test the feasibility of performing the QST across ages 6–18, and provide novel reference data of sensory thresholds for the knee of children aged between 9 and 18. To this end, a validated QST battery was used in children with JIA and healthy controls.Patients who visited the outpatient clinic of the pediatric rheumatology department were screened for eligibility. Patients were included if the following criteria were met: age between 6 and 18 years, able to speak and understand the Dutch language, JIA according to the International League Against Rheumatism (ILAR) criteria, inflammation in the knee, and a general pain score of 10 or more on a 0-100 mm patient Visual Analogue Scale (VAS). Exclusion criteria were: damaged skin on one or both knees, severe psychiatric co-morbidity, or active substance abuse. The study was designed as an observational cross-sectional case-control study. Cases and healthy controls were matched by age (within 1 year) and gender. The study was conducted in accordance with the Declaration of Helsinki , and approved by the ethics review board (protocol number 13–577). Written informed consent was obtained from all participants and from their parents or custodial caregiver.Patient characteristics were derived from the medical records. As part of standard of clinical care, a complete physical examination was performed by the rheumatologist, comprising the assessment of the number of active joints, Physician Global Assessment, and erythrocyte sediment rate (ESR).In addition, the Childhood Health Assessment Questionnaire (CHAQ) was provided by patient and/or parent, from which the disease severity score on a 0–100 scale was derived (with 0 being no disease activity and 100 being the most severe activity) . From thThermal detection thresholds for cold  and warm  stimuli. Thermal stimuli were applied using a thermal stimulation device with a 3 × 3 cm2 surface Peltier-type thermode . Thermal detection thresholds were determined by the mean of three consecutive stimuli.Thermal pain thresholds for cold  and hot stimuli . Stimuli were either continuously increasing or decreasing in temperature until the patient presses a button to indicating the detection of a change from a neutral sensation to a painful hot/cold sensation. Thermal pain thresholds were determined by the mean of three consecutive stimuli.Thermal sensory limen (TSL) was determined using a ramped increase from 32 degrees Centigrade upwards. The subject was asked to press a button as soon as the subject experiences a change of temperature to a warm sensation. Thereafter the temperature would decrease, and the subject was asked to press as soon as a cold sensation was perceived. This scheme was repeated for a total of six times and the TSL was determined based on the difference between the means of the two extremes in temperature.Mechanical detection threshold (MDT) is determined using a standardized set of modified von Frey hairs  that exert forces between 0.25 and 512 mN. The MDT was determined as the geometric mean of five consecutive series of ascending and descending stimulus intensities.Mechanical pain threshold (MPT) is determined using pinprick stimuli using a set of seven custom-made  weighted pinprick stimulators (flat contact area of 0.2 mm diameter) that exert forces between 8 and 512 mN. The MPT is the geometric mean of five consecutive series of ascending and descending stimulus intensities.Wind-up ratio (WUR) compares the numerical ratings of five series of a) a single pinprick stimulus  with five series of b) 10 repetitive pinprick stimuli at a 1/s rate. Each series of stimuli is applied within an alternating surface area of 1 cm2, immediately followed by an average numerical pain rating of the preceding series. The WUR is calculated as the averaged ratio: b/a.Vibration detection threshold (VDT) is determined using a Rydel–Seiffer 64 Hz tuning fork placed over the head of the fibula. Vibration threshold is determined with three series of diminishing stimulus intensities. The average of the three detection thresholds is used as the VDT.2 that exerts pressure up to 10 kg/cm2. Three series of ascending stimulus intensities are applied as a slowly increasing ramp of 0,5 kg/cm2 per second and the mean is taken as the PPT.Pressure pain threshold (PPT) is determined with a pressure gauge device  with a probe area of 1 cmMechanical pain / dynamic mechanical allodynia (ALL) assesses pain in response to stroking light touch . The three tactile stimuli are applied five times each with a single stroke of approximately 1–2 cm in length over the skin. This is pseudo-randomly alternated with pinprick stimuli of various forces as described above.QST was performed by trained personnel according to the QST protocol for children as described previously . In all All tests were executed in accordance with the protocol .Sample size was calculated based on published data on QST measurements in Patients with JIA , 16. DatIn order to detect a 38.5% difference in cold pain thresholds between the affected body regions in patients with JIA and control body regions in healthy controls with a standard deviation of 42.3%, a total sample size of 21 per age group was needed. Two age groups were defined: age 6 to 9, and 9 to 18. Sample size calculations were performed using G*Power 3 for a 2-tailed independent T-test. We assumed a type-I-error of 0.05 and a type-II-error of maximal 0.20. Based on the initial results from Blankenberg et al. [Data are represented as median and IQR, or mean and SD where appropriate. For the QST tests, one-way ANOVA with Tukey’s post hoc analysis was performed for parametric data, and Kruskall-Wallis test for non-parametric data. For the statistical analysis, R version.3.3.2 was used. Data were log-transformed where appropriate and z-values were calculated .In the age group of 6 to 9 years, participants were not able to complete the tests because of lack of understanding or inadequate attention span. After five inclusions within this age range, three subjects had not been able to complete the QST protocol. In this age group, the endpoint of feasibility had been reached (3 incomplete tests out of 21 yields 14% failure). Therefore we decided to only include and analyze children at an age of 9–18 years from that point on.N = 16) are shown in Table The demographic and clinical data of patients with JIA of the older age group . Moreover, even the unaffected unaffected control knee PPT thresholds of patients with JIA were lower than at the knees from healthy control subjects (p = 0.033). Pressure pain thresholds did not differ significantly between the affected and the unaffected knee of the patients with JIA (p = 0.93).  = 0.00979, p = 0.57), cold pain thresholds (p = 0.46), or mechanical pain thresholds (p = 0.67) of the affectedaffected knee of patients with JIA did not differ significantly from unaffected unaffected knees or knees of healthy control subjects , temperature sensory limen (p = 0.1), mechanical detection thresholds (p = 0.83), allodynia (p = 0.46), vibration detection thresholds (p = 0.3) and windup ratio (p = 0.31) did not significantly differ between the groups  and patient VAS were correlated  to pressure stimuli. Although others also have found that a unilateral inflammation induces a bilateral reduction in PPT in patients with JIA , we now Importantly, the most frequent site of involvement in JIA is the knee, and changes in sensory modalities specifically in the knee joint have not been studied in the context of JIA.n = 17) and in-active joints (n = 12). Whether the combined knee and ankle joint thresholds differed from that of healthy controls was not reported. In this study, we assessed sensory changes specifically at the knee of healthy controls and patients with JIA with an affected and unaffected knee. We observed that only two sensory modalities (CDT and PPT) at the knee were affected compared to healthy control knee. No significant differences were observed between the affected and unaffected knee, similar to what was previously observed when knee and ankle joints were combined [An earlier study  has inclcombined . An earlcombined  showed scombined .It is worth mentioning that apart from HPT, in this cross-sectional study, no QST modalities had a significant correlation with the magnitude of the reported pain. This is in accordance with the findings of Arnstad et al.  It is weOne limitation of this study is that the average duration of JIA was 6 years at the time of study. Thus the data represent sensory changes associated with chronic inflammation. Future studies could focus on sensory changes at the onset of rheumatic disease and how these changes correlate to pain levels during later stages of the disease. Also, in this population, medication was used extensively and ranged from NSAIDs to DMARDs. These drugs are known to have a dampening effect on pain , and as In conclusion, this study provides information that in Dutch children, the complete QST protocol is only feasible in the age group from 9 years and older, because children younger than 9 years were not able to complete the more extended DFNS QST test battery. In future studies, a reduced set of QST tests containing at least pressure pain thresholds and cold detection thresholds could prove to be better suited to the pediatric arthritis population, with the purpose of identifying patients with persistent changes in somatosensory processing in longitudinal studies. This would also reduce the 40 minutes test to roughly 10 minutes instead.Additional file 1. CDT, cold detection threshold; WDT, warm detection threshold; TSL, thermal sensory limen; CPT, cold pain threshold; HPT, heat pain threshold; MDT, mechanical detection threshold; MPT, mechanical pain threshold; VDT, vibration detection threshold; PPT, pressure pain threshold; WUR, wind-up ratio; ALL, allodynia. * Significant at 0.05.


Background: Pain secondary to chemotherapy-induced peripheral neuropathy (CIPN) can limit the administration of chemotherapy, cancer-treatment outcomes, and the quality of life of patients. Oxidative stress and inflammation are some of the key mechanisms involved in CIPN. Successful treatments for CIPN are limited. This report shows our preliminary experience using ozone treatment as a modulator of oxidative stress in chronic pain secondary to CIPN.Methods: Ozone treatment, by rectal insufflation, was administered in seven patients suffering from pain secondary to grade II or III CIPN. Pain was assessed by the visual analog scale (VAS).Results: All patients, except one, showed clinically relevant pain improvement. Median pain score according to the VAS was 7 (range: 5–8) before ozone treatment, 4 (range: 2–6) at the end of ozone treatment (p = 0.004), 5.5 (range: 1.8–6.3) 3 months after the end of ozone treatment (p = 0.008), and 6 (range: 2.6–6.6) 6 months after the end of ozone treatment (p = 0.008). The toxicity grade, according to the Common Terminology Criteria for Adverse Events (CTCAE v.5.0), improved in half of the patients.Conclusion: This report shows that most patients obtained clinically relevant and long-lasting improvement in chronic pain secondary to CIPN after treatment with ozone. These observed effects merit further research and support our ongoing randomized clinical trial (NCT04299893). Chemotherapy-induced peripheral neuropathy (CIPN) is one of the most relevant side effects of chemotherapy. Its presentation before the end of chemotherapy  can lead to the delay, reduction, or even interruption of the initially planned scheme of chemotherapy, with potential decreases in tumor control. On the other hand, chronic CIPN weeks or months after the end of chemotherapy can lead to persistent impairments in quality of life. CIPN happens in 70–100% of cancer patients after treatment with platinum-based drugs and 19–85% of cancer patients after different neurotoxic chemotherapies . A systeThe pathomechanism by which chemotherapeutics damage nervous system structures and cause CIPN is multifactorial and involves chronic oxidative stress (OS) and neuroinflammation . Based o3T) as an adjuvant treatment in the palliative management of patients with chronic pain secondary to CIPN.The aim of this report was to show our preliminary experience using ozone treatment . Compassionate ozone treatment in our hospital was assessed by the Health Care Ethics Committee, and this study was approved by the Provincial Research Ethics Committee of Las Palmas, Spain (Ref 2019-288-1). Informed written consent was obtained from all patients. See details in Between June 2019 and August 2021, 18 patients with different CIPN symptoms were submitted from Clinical Oncology and Radiation Oncology Departments to our multidisciplinary Chronic Pain Unit to evaluate complementary treatment with O3T, at the end of O3T, and at three and 6 months after the end of O3T.Pain, according to the Visual Analog Scale (VAS) ranging from 0 (no pain) to 10 (the worst imaginable pain), was assessed before O3T was administered by rectal insufflation on an outpatient basis. Ozone was obtained from clinical-grade oxygen using two medical ozone generators . The O3/O2 gas mixture provided by the device was administered via a rectal cannula using standard 60 ml syringes. The initial O3/O2 concentration (in µg/mL: µg of O3 per mL of O2) was 10 μg/ml, and it was increased by 5 μg/ml every two sessions until a final concentration of 30 μg/ml was reached. Typically, for each patient, the gas volume for insufflation started at 180 ml/session and was slowly increased in successive sessions (depending on patient tolerance of bowel bloating) up to a maximum volume of 300 ml/session if tolerated. The initially planned treatment consisted of 40 sessions over 4 months, with three sessions per week during the first 2 months and two sessions per week later, although the final number of O3T sessions could vary according to the clinical evolution.Op-values of <0.05 were considered statistically significant.The SPSS software package (version 15 for Windows) was used for statistical analyses. All data were described as median and range from 25 to 75%. Paired comparisons for quantitative variables were conducted with the exact significance Wilcoxon Rank test. Though more conservative than asymptotic tests, exact tests were used due to the small sample size. 3T was 17 weeks (range from 17 to 17), and the median number of O3T sessions was 40 (range from 40 to 40). One patient commenced with CIPN symptoms 10 months after the end of chemotherapy, and all the other patients commenced with symptoms before the end of chemotherapy. The median time from the initiation of symptoms to the commencement of O3T was 12 months (range from 10 to 48). The median follow-up after the end of O3T was 8 months (range from 6 to 20).The median duration of O3T, 4 (range from two to 6) at the end of O3T (p = 0.004), 5.5 (range from 1.8 to 6.3) 3 months after the end of O3T (p = 0.008), and 6 (range from 2.6 to 6.6) 6 months after the end of O3T (p = 0.008). See Painful CIPN was independently assessed in 11 different locations, four hands and 7 feet see . Six outThe toxicity grade according to the CTCAE v.5.0 classification decreased in four out of the seven patients .3T led to improvement in most patients with chronic pain secondary to CIPN, a frequent side effect of difficult management.This preliminary report showed that adjuvant treatment with rectal OThe pathogenesis and perpetuation of CIPN are multifactorial and may vary depending on the used drugs. Multiple involved mechanisms have been described as microtubule disruption, the alteration of calcium homeostasis and ion channel functions, DNA and/or mitochondrial damage, apoptosis, myelin sheath damage, and the induction of reactive oxygen species (ROS) by chemotherapy drugs with the further OS. At the same time, OS is linked to several of these factors, as well as to the induction of pro-inflammatory mediators that lead to immunological and inflammatory alterations . ROS can3T in the modulation of OS and inflammation in CIPN in detail (2O2), and the further and non-specific enhancement of adaptive antioxidant mechanisms, along with the transient upregulation of nuclear factor erythroid 2-related factor 2 (Nrf2). These effects are induced in a hormetic dose–response relationship. Therefore, the ozone effect is an “indirect effect” that does not follow a linear relationship. Significantly low ozone concentrations can have no effect, and significantly high concentrations can lead to undesired effects   and Beclin one expression, decreases phosphodiesterase 2A and NF-kB p65 expression, and reduces nerve apoptosis by blocking the NF-kB signaling pathway  . In addise-1-3-9  or normase-1-3-9 . Moreove pathway .Several other potential treatments based on the exogenous administration of antioxidants  have been evaluated for the prevention or treatment of CIPN, although without conclusive results to date . Overallp = 0.003), the magnitude of the improvement was modest, with a mean difference in average pain score of 0.73  between the duloxetine (1.06 score improvement) and placebo (0.34 score improvement) groups on a scale from 0 to 10 (Brief Pain Inventory-Short Form). These results show that further strategies for the management of chronic pain secondary to CIPN are required , even if two of them were treated with O3T during the second or the third line of chemotherapy . This is more than twice the reported percentage (38%) of patients with improvement in the placebo groups of other studies on pain due to CIPN (3T) compared well with the effect described for duloxetine. Third, although the O3T effect decreased over time, it remained clinically relevant 6 months after the end of O3T, which was associated with decreased requirements for pain killer drugs and increased daily living activities. This protracted effect also compared well with the effect described for duloxetine study, which did not address long-term duloxetine treatment beyond 5 weeks, and half of its effect was lost 1 week after the treatment was finished. The longlasting effect of ozone in painful CIPN agrees with the effect of ozone described 9 months after the end of O3T in patients with chronic pelvic pain secondary to radiotherapy  was administered in all patients except three . Patient #3 was treated with 300 ml most days, although volume was between 240 and 300 ml during the full treatment depending on the feeling of abdominal distension. In patient #4, O3T was administered during the second-line chemotherapy, which produced diarrhea and chemotherapy interruptions, and only 120 ml of gas was insufflated in the ozone sessions. Patient #6 presented self-limited episodes of abdominal pain with/without diarrhea after two O3T sessions with a gas insufflation of 300 ml; then, O3T was continued with 240 ml of gas insufflation without further problems. No other side effects were associated with O3T in the patient study group.The main side effect of O reports . The gas3T. Second, the sample comprised patients with different tumor locations and different chemotherapy treatments, although most patients were treated because of colorectal cancer or gynecological tumors using platinum-based drugs.This is a preliminary report with two relevant limitations. First, our study was a non-RCT with small sample size; however, they were patients refractory to conventional treatment after a median time of 12 months before the commencement of OAlthough this was a preliminary study, the magnitude and length of the observed effects and the limited therapeutical approaches for CIPN support further research with larger sample sizes, such as our ongoing randomized clinical trial (NCT04299893), to confirm our results.This preliminary report shows that most patients could obtain clinically relevant and long-term improvement in chronic pain secondary to CIPN after ozone treatment. The observed effects of ozone as an adjuvant treatment in the management of painful CIPN merit further research and support our ongoing randomized clinical trial.


Neck pain is a common musculoskeletal issue that has been seen as high in terms of disability. Muscle Energy Techniques (MET) are advanced soft tissue techniques to treat Mechanical Neck Pain (MNP). This study compares the Autogenic inhibition (AI) technique with the Reciprocal Inhibition (RI) technique providing conventional treatment to improve functional outcomes.randomization.com for a sample size of 80 and two groups of study ‘AI’ and ‘RI’ with a ratio of 1:1 by an independent statistician. Pain (primary outcome), range of motion, and functional disability (secondary outcomes) were assessed through visual analog scale (VAS), Goniometer, and Neck disability index (NDI) at baseline, 1st, and last session respectively. Mean and standard deviation, frequency, and percentages were calculated. Chi-square test and independent t-test compare baseline characteristics. The Repeated Measure Two-Way ANOVA compared mean VAS, NDI, and ROM. The significant P-value was less than 0.05.A randomized control trial was conducted at Sindh Institute of Physical Medicine & Rehabilitation, Karachi, Pakistan from August 28, 2021, to December 31, 2021 among 20–50 years old patients with Moderate intensity MNP for more than 4 weeks and with limited Neck ROMs. The sample were divided randomly and allocated into two groups (groups 1 and 2). Group 1 and 2 received 12 sessions of AI and RI with Conventional therapy respectively. The randomization sheet was generated online from p < 0.001) improvement in pain (ES = 0.975), disability (ES = 0.887), neck ROMs; flexion (ES = 0.975), extension (ES = 0.965), right and left lateral flexion (ES = 0.949 and 0.951), and right and left rotation (ES = 0.966 and 0.975) in the AI group than the RI group at 12th session.The mean duration of neck pain was 8 weeks. There was a more significant (The Autogenic Inhibition-MET is more beneficial than Reciprocal Inhibition-MET in improving Pain, Range of Motion, and Functional Disability in patients with Sub-Acute and Chronic Mechanical Neck Pain. Therefore, it is a beneficial technique to add with conventional neck pain therapy to get better treatment outcomes in MNP patients.NCT05044078.Prospectively registered on ClincalTrials.Gov with ID:  Neck pain is a common musculoskeletal condition ranked 4th highest in terms of disability. Out of 291 conditions, it is 21st in overall burden [Non-specific neck pain is pain with a postural or mechanical basis, also known as Mechanical Neck Pain (MNP) . MNP canManual therapy for MNP includes Muscle energy techniques that are advanced soft tissue active stretching techniques . It invoDisability from neck pain has a significant influence on employee productivity and the household economy. The financial burden of neck pain is second to low back pain in workers including increased treatment cost, pay cuts, and reimbursement . The curTo determine the effectiveness of Autogenic Inhibition and Reciprocal inhibition techniques with conventional therapy in Mechanical neck pain to improve Pain, Range of Motion, and Functional Disability.There is statistically significant difference in the effects of Autogenic Inhibition and Reciprocal inhibition techniques with conventional therapy in Mechanical neck pain to improve Pain, Range of Motion, and Functional Disability.This study is a Single Blinded, two-arm, Parallel design, Randomized Control Trial, with a group allocation ratio of 1:1. This study was conducted at the Physiotherapy Department of Sindh Institute of Physical Medicine & Rehabilitation, Karachi.The study population included patients who were 20–50 years old , have Mo+ S.D. of Cervical ROM (Extension) of AI 73.46 + 10.108 and RI 66.47 + 9.898 at the last treatment session, but due to low sample size, we increased the sample size to 80, means 40 patients were randomly allocated to 2 groups. Among the sample size of 40, 10 patients were included as a margin for drop-out patients.The sample size of 6 was calculated by the PASS software version 11 using 2 independent sample t-test for mean, confidence interval of 99 and 80% power of the test, mean The duration of the study was from August 28, 2021 to December 31, 2021.The data collection was started after the approval from Institutional Review Board, DUHS. All the patients were recruited after diagnosis by the physiatrist, in the absence of signs and symptoms of radiculopathy and myelopathy and based on inclusion and exclusion criteria. After recruitment, informed consent was signed. After that, the patient was assigned into 2 groups, GROUP 1  and GROUP 2  randomly divided by computer-generated software. Total 12 sessions, 3 sessions per week for 4 weeks were provided. To study the short-term effect treatment for 2 weeks has been provided previously . As our The consent form clearly stated the study objective, any possible harms, benefits, treatment techniques of both groups, confidentiality and withdrawal information along with the consent of voluntary participation with signatures of the patients. It was available in both English and Urdu for ease of understanding. The questionnaire used in this study was Neck Disability Index which was available in both English and Urdu as well. Permission and license for each version were granted by MAPI Research to the principal investigator.randomization.com for a sample size of 80 and two groups of study ‘AI’ and ‘RI’ with a ratio of 1:1 by an independent statistician. Initial screening was performed based on the inclusion and exclusion criteria of the study by a consultant physiatrist having experience more than 12 years. Then patients were referred to the physiotherapy department where, after informed consent and enrolment, they were randomly allocated to one of the groups using sealed envelopes that contained the treatment according to their group.The randomization sheet is generated online from This study was a single-blinded randomized controlled trial in which the outcomes assessor involved in the clinical trial has been prevented from knowing the interventions assigned to individual patients.All patients were given conventional therapy regardless of the study group. Conventional treatment includes Maitland PA central glides , in Grade 1 and 2 to decrease pain on the painful segments and isometric neck strengthening exercises  followed by superficial thermotherapy provided by the hot pack for 10 minutes on the back of the neck .Group 1 received AI-MET with conventional treatment while Group 2 received RI-MET with conventional treatment. AI and RI were applied to the muscles of the cervical spine, including Upper Trapezius , Sternocleidomastoid , levator Scapulae , and Scalene muscles .AI included stretching of the affected muscle and performing isometric contraction with 50% of the total patient’s effort in the same muscle that was being stretched and position hold for 10 seconds, with 5 seconds of rest after every repetition. This procedure was repeated 5 times. The RI also included stretching of the affected muscle but contrary to AI, isometric contraction of the antagonist muscles with the 50% of total patient’s effort was followed. This position holds for 10 seconds, while agonist’s muscle was still in the stretched position, with 5 seconds of rest after every repetition. This procedure was repeated 5 times too. The only difference between both techniques is that for autogenic inhibition we performed isometric contraction of the involved muscle while for reciprocal inhibition the isometric contraction of the antagonist’s muscle was performed, the overall procedure remained the same .For Upper trapezius muscle, the patient lay supine with the neck fully side bent and slightly rotated opposite from the side being treated. The therapist asked to move the ear towards the shoulder of the involved side and maintain against the resistance of the therapist’s hand for the AI technique. The therapist asked to move the ear towards the shoulder of the uninvolved side and maintain against the resistance of the therapist’s hand for the RI technique. For Levator Scapulae muscle, the patient lay supine with the neck in flexion, lateral flexion, and rotation. The therapist asked to take the head back in a neutral position towards the involved side and maintain against the resistance of the therapist’s hand for the AI technique. The therapist asked to take the head towards the uninvolved side of the chest and maintain against the resistance of the therapist’s hand for the RI technique .For the Scalene muscle, the patient lay in a supine position with a folded towel under the upper back and neck in slight extension and contralateral rotation. This technique was performed in 3 positions varying in the degree of rotations to target all anterior, middle, and posterior fibers of the scalene muscle. For posterior fibers neck was in full contralateral rotation and slight extension, for the middle fiber neck was in 45-degree contralateral rotation with slight extension, and for anterior fibers neck was in less than 45 degrees of rotation with slight extension, overall procedure remained the same. The therapist asked to rotate the head towards the involved side and maintain against the resistance of the therapist’s hand for the AI technique. The Therapist asked to rotate the head towards the uninvolved side and maintain against the resistance of the therapist’s hand for the RI technique . For SteIsometric neck strengthening exercises were performed in sitting position  and eachThe primary outcome measure used in this study were VAS for pain   on the line. The examiner scored the instrument by measuring the distance, in cm and mm, from the ‘no pain’ anchor to the mark, which the patient identified as their level of pain. Test–retest reliability has been reported to be highfor the VAS (ICC = 0.71–0.99). Concurrent validity has been found to be moderatefor the VAS (0.71–0.78) . The cutExcellent intra-rater reliability was present with Intraclass Correlation Coefficients  for goniometry ≥0.94 and digital inclinometry ≥0.95. The concurrent validity between goniometry and digital inclinometry was good with ICC  values of ≥0.85 . The tesFor Cervical Flexion and Extension, the goniometer center was placed over the center of the ear. The proximal arm was placed perpendicular or parallel to the ground. The distal arm was moved with nose tip or parallel to the longitudinal axis of the tongue depressor. For Cervical Lateral Flexion both sides, the goniometer center was placed over the C7 spinous process. The proximal arm was placed perpendicular to the ground. The distal arm was moved with the midline of the back of the head. For Cervical Rotation both sides, the goniometer center was placed on top of the head. The proximal arm was placed in parallel to the imaginary line between 2 acromial processes. The distal arm was moved with the nose tip parallel to the longitudinal axis .The NDI is available in English and Urdu. The NDI has been found to possess excellent test-retest reliability, strong construct validity, strong internal consistency, and good responsiveness in assessing disability in patients with mechanical neck pain (MNP) . The NDIThere are no harms and adverse event reported during the period of trial.P-value < 0.05 was considered significant. The result is presented in the form of tables. For categorical variables, frequency and percentages were shown for each group separately and combined. Educational and occupational status are presented in a pie-chart while the stage of the disease is shown by a bar chart. Also, for continuous variables mean, standard deviations, and lower or upper limit were shown for each group separately and combined. In another table, we present mean, standard deviation, lower and upper limit of VAS, NDI, and ROMs for baseline, 1st session, and the last session separately for both groups. Mean difference was calculated for within-group comparison. And p-value was shown for between-group comparisons.The Statistical Package of Social Sciences was used to analyze all the data. Mean and standard deviation calculated for Continuous variables. Frequency and percentage calculated for categorical variables. The association of the demographic variables between both groups at baseline is shown through the Chi-square test. An independent t-test was used to compare baseline characteristics of continuous variables. The Shapiro Wilk test statistically checked the assumptions of normality. For means comparison of VAS, NDI, and ROM, Repeated Measure Two-Way ANOVA was applied. The socio-demographical characteristics of all 80 patients are in Tables In Table p-value was < 0.05, which means a statistically significant (< 0.001) difference in disability scores between both groups present. The effect size of 0.887 shows large improvement in AI group as compared to RI group  between PIR and SS in terms of ROM in patients with cervical spondylosis [The range of motion can be easily measured by a Universal goniometer. The goniometer is a reliable and valid tool to measure cervical ROM . Goniomendylosis . They handylosis . Accordindylosis . While cThe findings of this study have to be seen in the light of the following major limitations. This study recruited the patients with non-probability purposive sampling technique due to the nature of patients’ characteristics requiring rehabilitation. There was comparative group instead of control due to objective of the study. However the control of all confounding factors and biasness was kept according to the consort guideline and we followed all consort guideline in the current study The change in pain intensity was limited to subjective findings of the visual analog scale only. The patients could misunderstand the requirement to complete its assessment. All patients were taught extensively regarding VAS before its administration. The ROMs measurement was assessed with a goniometer which could cause the manual error however the average value was taken to overcome this limitation. The disability measurement was limited to NDI which identifies superior responsiveness. Both English and Urdu versions were used but they lacked the emotional, social, and psychological factors related to disability. The same physiotherapist performed the intervention for both groups but was expert in both interventions equally.The present study concluded that Autogenic Inhibition (MET) is more beneficial than Reciprocal Inhibition (MET) in improving Pain, Range of Motion, and Functional Disability in patients with Sub-Acute and Chronic MNP. AI-MET showed remarkable improvement in terms of immediate and long-term effects on MNP across all outcome measures. Therefore, it is a good technique to add with conventional neck pain therapy to get better treatment outcomes in MNP patients.


This study was performed to utilize transnasal Sphenopalatine Ganglion (SPG) block for pain reliving during panretinal photocoagulation (PRP) in diabetic patients with diabetic retinopathy. This pre and post interventional study was performed on 20 patients with proliferative diabetic retinopathy. The first PRP treatment session of all the patients is performed with no transnasal SPG block, but before holding the second session, all the patients underwent transnasal SPG block and pain levels during and after PRP were compared to each other. Before the transnasal SPG block, each nostril of all the cases was inspected for finding any obstruction in each PRP session. Transnasal SPG block was also performed in with 2% lidocaine. The mean age of the included cases was 52.84 ± 8.62 years old (from 36 to 72 years old). All the cases underwent two PRP lasers treatment sessions with the same characteristic  for each patient. In the first and second PRP treatment sessions, the mean NRS scores were obtained immediately after the PRP laser (8.4 vs. 4.2), 15 min (8.2 vs. 4.2), 1 h (8.0 vs. 4.1), and 24 h (5.4 vs. 3.6) after the PRP respectively. The mean NRS scores significantly reduced during the second PRP treatment session compared to the first session (p < 0.001). Transnasal SPG block is a safe and effective strategy used for relieving pain caused by the PRP laser treatment in patients with diabetic retinopathy. Moreover, a study on the diabetic retinopathy identified that PRP with the placement of 800–1600 burns with 500-microns diameter and 0.1 s duration could induce at least 50% reduction in visual impartment within a 5-year period3. The main reason for the decreased burning delivered in these patients is pain during PRP laser5. Most of the cases undergoing PRP treatment complain of moderate to severe level of ocular pain during the procedure. In this regard, in previous studies, many authors have tried different strategies such as oral acetaminophen or intramuscular ketorolac, oral mephenamic acid, oral diazepam, oral or topical diclofenac, sub-tenon anesthesia, and peribulbar anesthesia for relieving pain during PRP, but there are no good evidences of the efficacy for any of them yet11. Moreover, other strategies such as transcutaneous electrical nerve stimulation12 and Entonox (50:50 nitrous oxide: oxygen gas) have limited its effects because of the need either for special equipment or invasiveness, or both of them. The sphenopalatine ganglion (SPG), also known as ptyergopalatine ganglion, is a large extracranial parasympathetic ganglion with multiple neural connections, including autonomic and sensory13. Accordingly, it is located in the upper part of the sphenomaxillary fossa in posterior to the middle nasal turbinate, from radiated nerves fibers to eyes. This ganglion is involved in pain processing through facial and trigeminal nerves as well as cervical sympathetic chain. Therefore, we thought that maybe we can reduce the pain during the PRP process with the SPG block. The history of SPG block dates back to when Sluder has reported that SPG block with cocaine could help in the treatment of headache and facial pain syndromes14. After a while, SPG block has gained interest as an effective strategy for management of headache such as cluster or migraine and facial pain syndrome15. Transnasal SPG block is an easy, effective, and safe method used for the treatment of acute migraine headache. Because of this ganglion’s involvement in pain processing of both face and eyes, in the current study, we aimed to use transnasal SPG block for pain reliving during PRP in diabetic patients with diabetic retinopathy.Diabetic retinopathy is known as the most important cause of visual loss in diabetic patients. The most acceptable treatment of visual impairment in diabetic patients caused by proliferative diabetic retinopathy, is the administration of panretinal photocoagulation (PRP) laserThis pre and post interventional study was performed to evaluate the efficacy of transnasal SPG block in pain relief during performing PRP laser for diabetic retinopathy among diabetic patients. Our study was conducted at Farabi hospital affiliated to Tehran University of medical sciences, Tehran, Iran, from March 2021 to September 2021. Moreover, it was approved by the ethical committee of our hospital and performed in terms of the tents of the Helsinki. All the included patients signed the informed consent form. The informed consent for publication of figure also was obtained. The inclusion criteria were the followings: diabetes diagnosed after the age of 30 years old, proliferative diabetic retinopathy, no history of PRP, intraocular pressure less than 21 mmHg, and clear vitreous (media). In addition, the exclusion criteria were the followings: previous PRP, cataract, vitreous hemorrhage, bleeding tendency, concomitant neovascular glaucoma, history of any psychiatric problem, severe abnormal neurological examination, the chronic use of analgesics, and history of allergy to local anesthetic. All the included patients underwent the complete ophthalmological examinations such as fundoscopy, tonometry, gonioscopy, bio-microscopy, and best-corrected visual acuity before performing PRP. As well, after the first session of the PRP treatment, they completed the pain sensation assessment scored based on a numeric rating scale (NRS), where 0 indicates no pain, and 10 is the worst pain imaginable. In order to perform papillary dilation, Mydrax 0.5% was administered 30 min before the PRP, for 3 times in each eye of all the patients. In case of any inadequate pupillary dilation, repeating the administration of dilating drop was allowed. Notably, the PRP treatments were performed only by one experienced retinal specialist (FB). The PRP was conducted using Argon green laser with a panretinal contact lens (superquad). Each session of PRP was done using the green laser (wavelength: 514) with spot size of 500 µm, in a duration of 0.2 s (200 ms), and power with a moderate intensity level (200–500 mW). A total of 1500–1800 spots were performed for each eye.The first PRP treatment session  of all the patients is performed with no transnasal SPG block, but before holding the second session of the laser treatment , all the cases underwent transnasal SPG block and pain levels during and after PRP were compared to each other. Before the transnasal SPG block, each nostril of all the cases was inspected for finding any obstruction in each PRP session. For patients’ comfort during this procedure, the anterior of each nostril was anesthetized with 4% lidocaine aerosol spray. Transnasal SPG block was also performed in each patient with 2% lidocaine in each nostril in supine position with head extension. To further reduce the patients’ discomfort, this procedure was conducted using a cannula in order to deliver lidocaine instead of cotton-tipped applicators. In this regard, a cannula preloaded with 2 ml of 2% lidocaine was inserted into the nostril along the upper border of the inferior turbinated directed backwards until reaching the upper posterior wall of the nasopharynx. Thereafter, 1 ml lidocaine 2% each at 5 min interval were administered for a 20-min duration  and Student’s paired t-test was also applied for continues variables. The statistical significance level was considered at p < 0.05.The patients provided written informed consent. The institutional review board/ethics committee of the Tehran University of Medical Science approved this survey.Written informed consents were obtained from patients.8 are shown in Table A total of 20 patients with both proliferative diabetic retinopathy who were candidates for PRP laser treatment, were enrolled in the current study from April to June 2021. Accordingly, their characteristics are summarized in Table 16. Therefore, it is necessary to decrease the pain during this procedure and increase tolerance level in patients who need PRP laser treatment. This study was designed due to relatively much pain during and after performing the laser that was shown to be able to affect the cooperation of patients. To the best of our knowledge, this study was the first aimed to present transnasal SPG block for decreasing PRP laser pain in patients. This study showed that transnasal SPG block is a safe, minimally invasive, and effective method used for pain relief during and after the PRP laser treatment in patients with diabetic retinopathy. The current research observed the decreased PRP laser pain during laser, 15 min, 1 h, and 24 h after performing the procedure in the studied cases. In this regard, the NRS scores decreased from 8.4 to 4.2 immediately after the PRP laser treatment. Moreover, in previous studies, no safe and effective agent or strategy could reduce laser pain in these patients. In previous studies, it was identified that acetaminophen, diazepam, mefenamic acid, and intramuscular ketorolac are not effective on pain reliving of PRP laser9. Moreover, some authors have employed numerous invasive strategies for reliving PRP pain such as sub-tenon anesthesia, and retrobulbar anesthesia, but these methods were indicated to possibly increase the risk of the potential events such as conjunctival and eyelid edema, akinesia of the eyelid, orbital hematoma, and globe perforation, so they are not suitable for use in offices18.Proliferative and non-proliferative diabetic retinopathies are known as one of the major causes of visual disturbance in diabetic patients. Additionally, it was shown that the PRP laser treatment is an effective strategy on decreasing the rate of visual loss in these patients. However, the PRP laser is a painful treatment for these cases, and the pain of laser intolerance leads most patients not to complete their laser procedure19. Another study has evaluated different diode laser pulse shapes and showed that the severity of pain with standard square-wave mode was more than the altered shaped wave and micropulse modes20. Finding an easy, non-invasive, and safe strategy for decreasing the pain level during the PRP laser treatment leads patients to better tolerate laser treatment, and most patients benefit from the PRP outcomes. The results of our study show that transnasal SPG block could provide statistically significant pain reduction both during and after PRP laser treatment. Some previous studies have concluded that the pain level of the second PRP treatment was significantly more than that of the first PRP laser session21. This difference might be resulted from the central sensitization of pain during the second PRP laser treatment. Therefore, when pain in the second PRP laser treatment was observed to be lower than the first session by using transnasal SPG block, this reflects the suitable effect of this block on controlling the pain in these patients.Other strategies for reduction this pain were alternations in laser parameters. In a study that compared the level of pain of short laser exposure (0.02 s) with that of traditional method (0.1 s), statistically significant less pain was found in the first group22. Therefore, we thought that using SPG block could help to reduce pain during PRP laser through the suppression of trigemino-autonomic reflex. Moreover, another mechanism explaining the possible effect of SPG block in decreasing pain through trigeminal nucleus was the afferent sensory fibers, which may reduce pain by reducing central sensitization24. The patients complained about having severe pain in and around their eyeball during PRP laser. Additionally, many patients’ complaints were related to radiate pain to the ipsilateral upper lid and some areas of the head such as forehead, temporal, and parietal during PRP laser. Of note, the sensory pathway of ocular pain is transmitted by the long ciliary nerve through nasociliary nerve and merging with the ophthalmic nerve25. It was shown that the ophthalmic nerve, which is the first branch of the trigeminal nerve, was stimulated during the PRP laser and then caused a painful sensation in the patients. Besides experiencing intraocular pain during the PRP laser, the patients often complained about pain around the eyes, which is related to pain sensation by the supraorbital, supratrochlear, and lacrimal nerves, all of which belong to the ophthalmic nerve26. Furthermore, it was shown that the pain during the PRP laser treatment is caused by the photocoagulation of long and short ciliary nerves running in the suprachoroidal space27. It is noteworthy that Ciliary ganglion includes sympathetic, parasympathetic, and sensory fibers. Therefore, it is expected that SPG block can help in reducing the PRP laser pain through sympathetic, parasympathetic, and sensory blocks. The sympathetic originates in the superior cervical ganglion around the internal carotid artery, which joins the greater petrosal nerve and then both form the Vidian nerve, which enters the SPG29. The parasympathetic preganglionic cell bodies originate in the superior salivatory nucleus in the pons, and in this way, parasympathetic nerves run in the nervus intermedius, form greater petrosal nerve, and finally enter SPG31. As well, the sensory fibers that carry sensation from tonsil, buccal, and palate through the maxillary nerve, enter SPG32. Therefore, the SPG can be considered as a special position that is involved in pain and central sensitization through multiple neural connections of sympathetic, parasympathetic, and sensory fibers. Based on previous findings, it was thought that transnasal SPG block could help to reduce PRP laser pain, which is not considered as an effective method to control their pain, and our study finally confirmed this hypothesis.Accordingly, the question that arises is how can the transnasal SPG block help in relieving pain during the PRP laser treatment? Many authors studied the mechanism of ocular pain during PRP laser. Previous studies have shown that migraine is triggered by the stimulation of trigemino-autonomic reflex, which is related to the increased parasympathetic outflow from SPG. SPG block can also help in pain relief of a migraine attack. SPG blocks cause reduction of neuroinflammatory mediators from sensory nerves such as substance P, acetylcholine, nitric oxide and calcitonin gene-related peptide by the inhibition of parasympathetic outflow and consequently led to the decreased intensity of pain and central sensitizationOur study has some limitations. The main limitation of our study was our small sample size. The other limitation of our study is that, in some patients may experience less discomfort after the first session and it may be influence our results. However, the significant differences were seen between 2 sessions and it can partly compensate some bias. In this study, we selected bilateral cases that never had PRP laser treatment before, in order to reduce any kind of bias. More well-designed studies like clinical trials are needed to evaluate the efficacy of transnasal SPG block in reducing pain during the PRP laser treatment.Finally, it can be concluded that transnasal SPG block is an easy, safe, and effective strategy used for relieving pain caused by the PRP laser treatment in patients with diabetic retinopathy. Some advantages such as its ease of administration, safety profile, and effective pain relief make this method an attractive treatment option for patients who cannot benefit from PRP laser treatment due to having pain. However further studies with well-designed and more cases are required for the efficacy of SPG block.


Therefore, the present case report study aims to evaluate the effects that a 60 min session with the EXOPULSE Mollii suit has on a female fibromyalgia patient. After the intervention, we can conclude that a 60 min session with the EXOPULSE Mollii suit has beneficial effects on pain perception, muscle oxygenation, parasympathetic modulation, and function in a female fibromyalgia patient.Fibromyalgia is a chronic disorder characterized by widespread musculoskeletal pain and associated fatigue, sleep disturbances, and other cognitive and somatic symptoms. A multidisciplinary approach including pharmacological therapies along with behavioral therapy, exercise, patient education, and pain management is a possible solution for the treatment of this disease. The EXOPULSE Mollii Fibromyalgia is a chronic disorder characterized by widespread musculoskeletal pain and associated fatigue, sleep disturbances, and other cognitive and somatic symptoms , with a ® method  could be considered an evolution of the TENS system, as it is an innovative approach for non-invasive and self-administered electrical stimulation with multiple electrodes incorporated in a full-body suit [Further, the use of electrical stimulation with surface electrodes is a non-invasive therapeutic method used in patients’ central nervous system injuries, improving voluntary motor control and range of motion and reducing pain and spasticity . Moreoveody suit . This meody suit ,20. Addiody suit . Furtherody suit , spasticody suit , and chrody suit . TherefoThe present study consists of a case report conducted to ascertain the acute effects of a treatment session with the EXOPULSE Mollii suit on a fibromyalgia patient.2 Body Mass Index (BMI).A female fibromyalgia patient of 43 years of age and 1 year of diagnosis, weight of 85 kg, 164 cm height, and a 30.8 kg/cmThe treatment with the EXOPULSE Mollii suit is described by the manufacturer as using 60 min sessions, with effects that vary between patients and that can last up to 48 h . TherefoAll variables were evaluated prior to the intervention in basal conditions, and after the intervention.The hot point was automatically assessed by a FLIR E8-XT system . Two meaTo measure the following variables, a spirometry test was conducted with a Vitalograph Asma1 spirometer . The patTo assess pain severity, the Numeric Rating Scale (NRS) was used with a scale of 0–10, with 0 meaning “no pain”, and 10 meaning “the worst pain imaginable” .2), total hemoglobin (THb), deoxygenated hemoglobin (HHb), and oxygenated hemoglobin (O2Hb) values were measured using a portable NIRS sensor  connected with the GoldenCheetah software . This device, shown to be reliable at low and moderate intensity for the measuring of consumption of muscle oxygen  [® software . In the following, we used a second-order 6 Hz cut-off Butterworth filter, applied two times to the time series.Muscle oxygen saturation (SmO3–0.992) , was plaCortical arousal was measured through the Critical Flicker Fusion Threshold (CFFT) in a viewing chamber (Lafayette Instrument Flicker Fusion Control Unit Model 12021), following the procedure conducted in previous studies ,38.Adapted from the exercise test battery by Carbonell-Baeza et al. (2022) for fibromyalgia patients .Chair stand test: the number of times within 30 s that an individual can rise to a full stand from a seated position with back straight and feet flat on the floor, without pushing off with the arms.Handgrip strength test: measured using a grip dynamometer . Each patient performs the test twice with the dominant hand, with the arm fully extended, forming a 30° angle in relation to the trunk.10 m up and go test: consists of standing up from a chair and walking 10 m in the shortest time possible without running.One leg balance: the subject must keep balance on one leg with their eyes open as long as possible. This test is conducted on both legs.2.To obtain an estimate of the participant’s general pain sensitivity ,41, presg for 10 min to remove food and cell debris, and the supernatant was stored at −20 °C until analysis. Preceding analysis and saliva samples were thawed on ice and centrifuged for 30 min at 4 °C, 13,000× g, for removal of mucinous material [Unstimulated whole saliva was collected at rest and after exercise for each participant by direct draining into an ice-cold collection tube (pre-weighted) for 3 min. Subjects refrained from eating and drinking for at least 1 h before collection. After saliva collection, tubes with the samples were weighted , centrifuged at 1500× material . Supernamaterial .The statistical software SPSS  was used to perform the statistical analyses, with data being presented as mean ± standard deviation (SD).The current study followed the ethical standards recognized by the Declaration of Helsinki , the EEC2 and O2Hb after the intervention , while HHb decreased after the intervention , and there was no change in THb .Muscle oxygen values are present in Further on the Functional test results are present in In 2, and the changes in HHb and O2Hb distribution, with both values being more equal than before the intervention. These findings are in line with previous research on muscle oxygenation in fibromyalgia patients, which states that fibromyalgia patients have lower SmO2 and O2Hb and higher HHb compared to healthy controls [2 from 41.8% to 52.2% after the intervention, although it did not reach healthy population normal values of around 70–75% [The present study is a novel case report study in the use of the EXOPULSE Mollii suit in a fibromyalgia patient procedure that has never been carried out in a scientific setting. As such, there is no previous research on this actual topic to compare our results with. Along this line, the main findings of our study are the drastic change in muscle oxygenation, with a 10.4% increase in SmOcontrols . Authorscontrols . Howeverd 70–75% . Furtherd 70–75% , and as Along this line, the patient performed better in all tests after the intervention, which could be attributed to this increase in muscle oxygenation, or to a better ATP production and the reduction in pain allowing the patient to better exert herself in the tests. Further, we should highlight the increase in balance with the right leg, where the subject went from holding only for 3 s to being able to maintain balance for 30 s before having to stop. As previously stated, this increase in performance could be attributed to the reduction of pain, or to the better oxygen usage acquired after the intervention. However, further research should be conducted on the duration of these effects, and whether these effects could be made chronic with successive sessions.Furthermore, it has been demonstrated that fibromyalgia patients have a higher sympathetic nervous system activation in basal conditions than healthy individuals, which is consistent with a decrease in salivary flow ,52. AlonTo summarize, in this study, we have found significant changes in muscle oxygenation, functional test performance, and subjective pain perception measured through the NRS, saliva flux, and hand temperature, which in turn suggest a better mitochondrial function and an increase in parasympathetic tone. Along this line, now that a successful case report has been produced, it would be of great interest to implement this same procedure with a wider sample. Moreover, the duration of these acute effects on this fibromyalgia patient should be studied, and the effects of successive sessions should also be studied.We can conclude that a 60 min session with the EXOPULSE Mollii suit has beneficial effects on pain perception, muscle oxygenation, parasympathetic modulation, and function in a female fibromyalgia patient.


Low back pain is a common presentation to emergency departments, but the reasons why people choose to attend the emergency department have not been explored. We aimed to fill this gap with this study to understand why persons with low back pain choose to attend the emergency department. Between July 4, 2017 and October 1, 2018, consecutive patients with a complaint of low back pain presenting to the University of Alberta Hospital emergency department were screened. Those enrolled completed a 13-item questionnaire to assess reasons and expectations related to their presentation. Demographics, acuity and disposition were obtained electronically. Factors associated with admission were examined in a logistic regression model. After screening 812 patients, 209 participants met the study criteria. The most common Canadian Triage and Acuity Scale score was 3 (73.2%). Overall, 37 (17.7%) received at least one consultation, 89.0% of participants were discharged home, 9.6% were admitted and 1.4% were transferred. Participants had a median pain intensity of 8/10 and a median daily functioning of 3/10. When asked, 64.6% attended for pain control while 44.5% stated ease of access. Most participants expected to obtain pain medication (67%) and advice (56%). Few attended because of cost savings (3.8%). After adjustment, only advanced age and ambulance arrival were significantly associated with admission. In conclusion, most low back pain patients came to the emergency department for pain control yet few were admitted and the majority did not receive a consultation. Timely alternatives for management of low back pain in the emergency department appear needed, yet are lacking. Low back pain (LBP), a leading cause of disability in Canada , affectsDespite this information, little is known about why people with LBP choose to come to the ED when other options are available in the community. In counties with universal publicly–funded health care like Canada, these options include no-cost access to primary care providers in the community and access to fee-for-service allied health care professions . This is an important question as very few patients with LBP who present to the ED are admitted to hospital. In many hospital settings, less than 10% of LBP cases presenting to the ED are admitted . These lGiven the above, the objective of this study was to document the reasons that persons with LBP present to the ED as they pertain to accessibility, social and economic domains. In addition, factors associated with admission were examined in an effort to generate future hypotheses. To our knowledge, the answers to these questions have not been reported previously in the emergency literature.This was a prospective observational, monocentric study whose target population was those presenting to the University of Alberta Hospital Emergency Department (UAHED) with a complaint of LBP. The UAHED is a major urban teaching center located in Edmonton, Alberta, Canada (population = 1.3 million {2017}), with approximately 75,000 adult patient visits per year. It is a trauma, burns, transplant and pediatric centre staffed by full time emergency physicians and learners from a variety of specialty programs. A total of 11 clinical shifts of eight hours duration are employed to staff the adult side of the UAHED. At the time of the study, no other health care professionals  were employed at this site. At this institution, the on-call spine service alternates daily between Orthopedic and Neurosurgical services.Included participants were persons aged 18 years of age or older visiting the UAHED with who self-reported LBP. Those who were deemed competent to provide informed consent were eligible for the study. At triage, Canadian Triage and Acuity Scale (CTAS) scores  were assThose excluded from the study were considered to have cognitive impairment, were enrolled previously in the study, attended for direct consultations, or were patients presenting to UAHED under police escort. Further, patients who were unable to read or communicate in English were also excluded, unless a friend or family member was able to assist in the completion of the collection of study materials. Patients who were feeling too unwell, due to nausea, pain, emotional instability, or intoxication, but improved before the end of the study recruitment shift, were approached to participate in the study. A Refused, Missed, and Other exclusion (RMO) minimal data log was maintained . In addition to those patients approached directly by the research assistants, a sign was approved and posted in the ED informing those in the waiting room about the study. Interested patients followed the informed consent process detailed above.The study protocol was approved by to the Biomedical Panel of the Health Research Ethics Board (HREB) at the University of Alberta (Pro00049637). Operational/administrative approval was provided by Alberta Health Services (AHS) to permit data collection at the study site.The study questionnaire was developed from a prior pilot mailout survey with a subsequent response rate of ~ 15% . Based oOn most occasions, the research assistant approached and interviewed the patient prior to an emergency physician seeing the patient. During the interview, if a physician or nurse needed to assess the patient, the interview was completed after their assessment. Participation in the study was voluntary, no incentives were offered to patients for participation, and completion did not delay direct patient care. The questionnaire was taken only by those who provided consent and in no way affected their care.Enrollment commenced on July 14, 2017 and ended June 30, 2018.All responses were collected on paper forms and checked for completeness by our research staff. All data were then entered into a password protected Research Electronic Data Capture (REDCap) website  located on a secure University of Alberta server. The only unique participant identifier was the participant study number.Participant names and identifying characteristics were not recorded on the study materials; however, a master form was retained until data capture was complete. All data were entered into the electronic repository as de-identified data following verification and stored on secure servers within the Faculty of Medicine & Dentistry at the University of Alberta.The study questionnaire was designed to answer our research question within the shortest period of time . QuestioIn addition to data collected from the questionnaire, de-identified administrative data for the study period were provided by Data Information and Measurement Reporting (DIMR) within Alberta Health Services (AHS). Additional data contained information on demographics , ED arrival information , ED visit times , disposition , and post-ED outcomes .There was a need to balance research effort and available resources with sample size. For example, enrollment of ~250 participants would provide reasonable precision around mid-range observations  as well as low  incidence observations. To obtain 95% CIs approximating ±1% at the mid-range of estimates, enrollment of more than 5000 participants would be needed, which was not feasible.2) statistics. Parametric continuous data are reported as means with standard deviations (SD) and comparisons were completed using unpaired t-test. Nonparametric continuous data are reported as medians with interquartile range , and comparisons were completed using Wilcoxon rank-sum tests. Factors associated with admission were examined in a logistic regression model using univariate associations at the p <0.2 level as well as common variables from the literature. Variables were entered into the model in a stepwise fashion and deleted when they had a p >0.05 in the combined model. Odds ratios (OR) and 95% CIs are reported for unadjusted and adjusted comparisons. Significance for all tests will be set at p <0.05.All study data were exported from REDCap into STATA®  for analysis. Dichotomous results are reported using proportions and comparisons were conducted using Chi-square , the male to female ratio was 1:1, and most presented with CTAS 3 severity (153 {73.2%)). Delays to physician initial assessment (median 2.8 hours) and prolonged median length of stay for discharged (5.4 hours) and admitted (13.6 hours) patients indicates an ED suffering from overcrowding. The most common visit outcome was discharge ; however, hospitalization  and transfer to another facility  also occurred.Visit characteristics are described in Responses to the 13-questions  are presFactors associated with admission to hospital on univariate analyses were explored using logistic regression. Biological sex was not associated with admission ; however, it was considered clinically important and was therefore retained in the final model to correct possible confounding. Overall, after adjustment, only advanced age  and arrival by ambulance  were significantly associated with admission.Low back pain is an exceedingly common health compliant and when severe, may precipitate a presentation to health care settings, including the ED. This study collected data from consecutive patients presenting to a high-volume, high acuity hospital ED in Western Canada to examine reasons and expectations for presenting to the ED with a complaint of LBP. While numerous studies have evaluated the demographics and visit characteristics of LBP patients in the ED, it is rare for researchers to directly query motivations for attending an ED for LBP.Our research question, “Why do people with LBP choose to come to the ED” implies that people have a choice of where to seek care. As such, we excluded people who might not have had this choice. This would potentially include patients arriving with a CTAS score of 1 or 2 who would not have made their own choice to come to the ED . In contrast, we included persons brought to the ED by ambulance. Overall, this patient sample was collected without bias, and represents a typical group of patients with LBP in Canadian EDs.The percentage admitted to hospital in our study with an initial presentation of LBP was close to 10%, a value similar to admittance rates from other Canadian studies , 3. Our What our demographic results tell us is that our study population is consistent with other studies that have investigated ED patient profiles; the LBP ED population tends to be older and fairly equal in sex distribution , 3. Our In addition to pain levels, a second prominent reason that patients attended the ED for LBP was related to uncertainly in pain etiology. Overall, back pain conditions having a definitive etiology make up about 10% of the total number of cases . As suchIn this tertiary care ED, patients with LBP received delayed assessment and experience prolonged lengths of stay, even when discharged from the ED. Delays have been associated with poor outcomes  and thisOf course, all of the above reasons for attending the ED for LBP may vary according to individual patient expectations. Many participants were expecting medication (most likely those with acute pain) while many were expecting imaging–something that is overused in back pain and especially so in the ED , 19, 20.The main strength of this study was its prospective nature. While we consecutively screened ED presenters over the course of the study period, we were not able to provide research coverage on nights and weekends. This is common in ED-based studies and does not invalidate the results reported. While more severe cases may present at night and perhaps on weekends, this sample includes some patients that arrived overnight/weekends and better represents the populating that had the opportunity to seek alternative care elsewhere. In addition, we excluded patients with extreme pain; however, while we were seeking patients with low acuity LBP, the median pain scores were high for both admitted and discharged patients . This study was the first to use a 13-item questionnaire whose psychometric properties have yet to be fully validated. Although different cities, jurisdictions, countries and economic factors likely play a role in shaping who presents to the ED for LBP, it may be possible to generalize these results across countries like Canada where universal health care exists.Overall, our data suggest that most patients with LBP present to the ED when their pain is severe and they are seeking pain control and/or they have diagnostic uncertainty. Overall, most patients and providers would agree that the ED is not an ideal location to clarify the diagnosis of chronic conditions; however, without addressing underlying issues related to patient choosing the ED for LBP, issues with timely ambulatory care, lack of guidelines and other factors, the rising trend of ED presentations will not likely change. With these results, future studies should focus on intersectionality issues  and how they may affect the decisions of these patients.