Background: Rheumatoid Arthritis (RA) is a systemic and inflammatory disease of unknown etiology which is mostly characterized by inflammation of the synovial joints. Studies have proved that most people with RA avoid doing physical activities due to fear that it may worsen the pain or cause pressure on joints, resulting in decreased muscle strength and ultimately leading to disability of patients. We aimed to investigate the effects of conditioning exercises on the health status and pain in patients suffering from RA.Methods: In this randomized controlled clinical trial, we enrolled 66 women with confirmed RA referred to the rheumatology clinic of Hafez hospital, Shiraz, southwest Iran during May-July 2013. Balanced block randomization method was used to randomize the participants into case and control groups (two groups of 33 each).Data were collected using visual analog scale (VAS), Arthritis Impact Measurement Scales 2 short form (AIMS2-SF), and demographic questionnaire. After obtaining written informed consent, the participants in the case group were asked to participate in conditioning exercise programs including aerobic, isometric, and isotonic exercises and received a training booklet explaining the exercises that they could do at home after the intervention.Results: There was a statistically significant difference between the health status scores of the patients in the case groups before and after the intervention (P=0.001). The pain score also decreased significantly in the case group compared with the control group after the intervention (P=0.003).Conclusion: We concluded that physical training programs, especially conditioning exercises, could improve the health status and reduce pain in patients with RA.Trial Registration Number: IRCT201308187531N3 RA initially involves the small hand or feet joints and it spreads to the larger joints during its progression. While such disease may be transient, it usually becomes chronic and causes destruction of the joints sooner or later (in few months or year).2,3Rheumatoid Arthritis (RA) is a chronic disabling disease which is mostly manifested by inflammation of the synovial joints. This autoimmune disease results in progressive joint destruction and deformity leading to varying degrees of limitations in daily activities.2,4 However, its prevalence varies in different populations, for example in people with family history of RA; its rate is approximately 2-3%.4,5 Besides, the mortality rate of those affected is twice that of general population at the same age. The prevalence rate is significantly increasing in the recent years.2,6 Currently, more than 2 million people in the United States are suffering from RA while it is predicted that by 2020 the number of the patients increases to more than 18% due to the increased longevity of the population.7,8 Its prevalence and incidence increase with age. Furthermore, women are more likely to develop such disease than men as 70% of the patients suffering from the disease are women. Men are affected with more severe form of RA. According to several studies, its global prevalence rate is reported 0.5 -1% worldwide.2,9 and may cause numerous physical complications. Chronic pain, fatigue, impaired mobility and limb deformities are the major complications induced by the disease.10 Its symptoms, such as stiffness of the joints and movement disorders, are progressive to the extent that a number of the patients lose their mobility and activity and are almost entirely paralyzed and crippled. Mobility problems may impose major damages and complications on both the patient and society, and may have negative effects on them physically, socially, psychologically and economically.2,11This disease, which mostly occurs in the fourth and fifth decades of life, can disrupt normal daily activities11 Rheumatologic studies have shown that exercising could positively affect their quality of life by reducing muscle pain and stiffness.12 It can also reduce symptoms of anxiety and depression and the recurrence frequency of chronic pains.13It is essential to maintain physical performance in patients with RA so that they can perform self-care activities. Accordingly, regular exercise can decrease the pain, fatigue, and morning stiffness in patients and increase their self-confidence.14,15 It can result in decreased muscle strength and aerobic capacity and ultimately lead to disability of patients.15 In patients with RA, the muscles around the joint may become weak if the joints cannot move strongly. Therefore, physical and exercise therapy is effective in pain reduction and improving range of motion around the joints by strengthening the muscles that surround the joint and reducing the pressure on them.Studies have proved that most people with RA avoid doing physical activities due to fear that it may worsen the pain or cause pressure on joints.11,16 Physical activity,specially group exercising, can improve social interaction and increase the sense of well-being.16 The short-term effects of strengthening exercises on the patients with such disease have well been described in several studies; however, only a few studies have considered the long-term effects of exercising on the patients’ muscle strength and activity.1Performing physical exercises is beneficial in improving respiratory capacity as well as physical and functional strength in patients with RA.17Conditioning exercise is an activity which improves cardiovascular and muscle endurance as well as muscle strength including aerobic exercise, plyometrics, calisthenics, and exercises based on real-life motions. It increases the energy capacity of the muscle and is primarily involved in developing skills. Different types of conditioning exercises can be used depending on fitness goals as they could be adopted to any level of fitness (from beginners to experienced athletes).18 The importance of exercising has been proven and clarified in the management and treatment of RA. Generally, physical exercise could improve the performance of the patients with such disease. Hence, all of the patients suffering from such disease should be encouraged to participate in some types of physical exercises as a part of their daily routine-activities. Therefore, we aimed to investigate the effects of conditioning exercises on the health status and pain in patients suffering from RA.Besides, a study performed on 20 women with RA showed that isometric and isotonic strengthening exercises combined with 15 minutes of cycling not only do not worsen the disease but also improve physical strength and performance in such patients.This study was anopen randomized controlled clinical trial, approved by the Ethics Committee of Shiraz University of Medical Sciences. We enrolled 66 women with confirmed RA according to ACR 2010 (American College of Rheumatology) by a rheumatologist who referred to the rheumatology clinic of Hafez hospital, Shiraz, southwest Iran during May to July 2013. Of them, 2 were excluded from the study as they did not meet inclusion criteria or declined to continue participation. The protocol of the study participants has been shown in 1 also, using Power SSC statistical software  and considering the following formula, the predicted loss samples were taken from 66 patients.The sample size was calculated as 32 in each group based on the data of a similar study conducted by Stefano Masiero (2007);n=26(Z1-a/2+Z1-B)^2/(µ1-µ2)The inclusion criteria were: confirmed diagnosis of RA, age of 18 or more, willingness to participate in the study, ability to perform the exercises twice a week, ability to understand and communicate in Persian language, residence in the city where the study was done, and lack of osteoarthritis or any other inflammatory articular diseases. Exclusion criteria were suffering from severe form of the disease, any changes in the treatment of articular therapy in the last 6 months or during the study, need to change the treatment, performing Joint surgery in the 6 months before the intervention, participation in a similar training programs, and absence of more than two sessions in training program. Besides, in case of need to change the treatment for the patients, they were excluded from the study; however, we had no such case.After obtaining written informed consent, the researcher explained the aims and method of the research to the patients who were willing to participate in the study and asked them to complete the questionnaires. Data were collected using visual analog scale (VAS), Arthritis Impact Measurement Scales 2 short form (AIMS2-SF) and demographic questionnaire containing information about age, age of occurrence of the disease, duration of the disease, educational level, employment and marital status.19 The items are answered with options ranging from “all days” to “no days” in the previous four weeks. All the items are measured on a five-point Likert scale scored from 1 to 5.The total scores range from 26 to 130. The reliability and validity of AIMS2-SF were assessed in some studies and were also estimated in Iran by Askary-Ashtiani and colleagues (2009) on 350 patients with RA and Cronbach’s alpha was calculated as 0.74-0.89.20AIMS2-SF is a self-reported questionnaire with 12 scales to assess five components of health status in patients with arthritis: physical (12 items), symptom (3 items), affect (5 items), and social interaction (4 items), and role (2 items) components. The 26-item AIMS2-SF is a shorter version of the AIMS2  which was developed by Gullemin and colleagues.The pain VAS is an instrument in which pain intensity is rated on a four-point scale . The scale is anchored by “no pain”  and “worst imaginable pain” .The case group then was divided into two groups of 16 participants each. They were asked to participate in conditioning exercise programs consisting of two 45-minutes sessions per week for 8 consecutive weeks and were trained by the researcher. Conditioning exercises included aerobic, isometric, and isotonic exercises. Moreover, the patients received a training complied with the routine program of the clinic.Immediately after the intervention, the VAS and AIMS2 questionnaires were completed again by the participants of both case and control groups. Finally, the patients in the control group received the same booklet. The collected data were analyzed using SPSS software, version 18. The significance level was set at <0.05.The age range of the patients was 23-63 years. Their mean±SD ages was 48.6±10.51 and 48.87±9.24 in the case and control groups, respectively. The mean±SD age of the occurrence was 39.00±10.23 and 40.28±7.80 years in the case and control group, respectively. According to independent t-test, there was no significant difference between the two groups with respect to their mean age (P=0.74) and mean age of occurrence (P=0.57).The mean duration of the disease in the majority of the studied cases (64%) was more than 5 years and Chi-square test showed no significant difference between the two groups in this regard (P=0.20). 84.4% of the participants in the case group and 87.5% of those in the control groups were married (P=1.00). 50% of the patients in both groups did not have secondary education. Furthermore, 71.9% of the participants in the case group and 78.1% of those in the control group were housewives. Chi-square test showed no significant difference between the two groups as to the marital and occupational status as well as educational level. Both groups of the patients were homogeneous with respect to their demographic characteristics.We found no significant difference between the case and control groups with respect to the pain score before the intervention (P=0.39). Therefore, the participants were all in the same status regarding the amount of pain they experienced. However, the pain score decreased in both groups of the patients immediately after the intervention and such decrease was only statistically significant in the case group based on Wilcoxon test (P<0.001), demonstrating the effect of exercise training intervention on pain relief among the participants of this group. Therefore, exercise interventions, on one hand could be used as an appropriate solution in decreasing pain, and on the other hand, it could increase the ability of the patients to manage their own condition.21 Similarly, according to the study conducted by Teybi-Sabet, performing appropriate physical exercises could desirably reduce the pain and slow the process of the disease.22Our findings were consistent with those of the studies which confirm that participation in exercise programs is effective on pain reduction in patients suffering from RA. Moreover, Flint-Wagner and colleagues (2009) conducted a study on 24 patients with RA in United States to investigate the effect of a 16-week training program on strength, pain and function. They found out that training could decrease the pain and improve function in the patients.23 Mohammadzadeh and colleagues also revealed that exercising in water (hydrotherapy) could positively lead to pain relief in the patients with RA.11 Likewise, Cadmus et al. concluded that a 10-week aquatic exercise program could help to reduce joint pain and improve the quality of life in patients.24 Eyigor and colleagues also suggested that physical therapy techniques, such as physiotherapy and isometric exercises, could reduce pain in those with osteoarthritis.25In a study conducted by Kalali Jouneghani and colleagues, the severity of pain in the participants in the case group decreased significantly compared with those in the control group.1 Generally, management of such disease is established upon a treatment pyramid in which the pain relief is considered as its main base.26 Our findings showed no statistically significant difference between the two groups with respect to the mean score of all dimensions of health status before the intervention. However, the mean score increased immediately after the intervention and such increase was statistically significant in all dimensions of health (P<0.001).In the control group, the mean score increased in the dimensions of role and affect but decreased in the dimensions of physical health, symptoms and social interaction; however, such changes were not statistically significant in any of dimensions. Furthermore, Masiero et al. compared the mean difference of the pain score between the two groups of participants after 8 months and found out that it was only statistically significant in the case group.27 Moreover, after conducting another study on 120 patients with knee osteoarthritis, the researchers reported improvements in the health status of the patients in the case group and no statistically significant changes in the control group.28Our findings were similar to those of De Jong and colleagues (2003) since in their study, conducted on 306 patients with RA, a twice-a-week training program improved the functional ability and health status of the patients.21 Our findings were also inconsistence with some other studies, confirming the efficacy of training and exercise in the improvement of health status in patients suffering from RA.1,29,30 Similarly, Katz concluded that inability in performing daily activities is common among such patients.31Besides, the findings of another study showed significant improvements in the patients’ strength, pain and function.2,11 Previous studies have shown that physical exercise trainings and interventions could improve the health status of the patients with chronic diseases.32As mentioned before, physical complications of the disease are progressive to the extent that a number of such patients are almost entirely paralyzed and crippled. Therefore, rehabilitation programs should be used to help the patients to maintain their physical performance. They should also be taught how to cope with the disease and its consequences.33 Besides, community health nurses can help their patients to maintain flexibility, muscle strength, and bone mass by counseling about nutritional practices and encouraging adoption with exercising which can improve the muscles strength.16Nurses and their abilities in training the patients have an old history as Nolan believes that nurses can do interventions in the field of pain relief, nutrition and mobility, self-care, creating positive images and increasing self-confidence in the patients.It can be concluded that physical training programs,especially conditioning exercises including aerobic, isometric, and isotonic exercises,could improve the health status and reduce pain in the patients with RA. Physical exercising is an appropriate intervention on the patients since it could not only maintain the patients’ physical health but also positively affect their psychological and social dimensions. However, more research is required to examine the stability of the efficacy of training programs on the health status and pain relief in the patients.


Despite a favorable clinical experience, little evidence exists for the efficacy of greater occipital nerve block (GONB) in migraine treatment. Considering such a premise, we wished to evaluate the therapeutic efficacy of GONB in patients affected by migraine headaches.A randomized double-blinded controlled trial was conducted on 48 patients suffering from migraine headaches. A syringe containing 1.0 mL of lidocaine 2%, 0.5 mL of either saline  or triamcinolone 0.5 mL  was prepared for each patient. Patients were assessed prior to the injection, and also 2 weeks, 1 month, and 2 months thereafter for severity and frequency of pain, times to use analgesics and any appeared side effects.No significant differences were revealed in pain severity, pain frequency, and analgesics use between the two groups at the four study time points including at baseline, and 2, 4, and 8 weeks after the intervention. However, in both groups, the indices of pain severity, pain frequency, and analgesics use were significantly reduced at the three time points after the intervention compared with before the intervention.GONB with triamcinolone in combination with lidocaine or normal saline with lidocaine results in reducing pain severity and frequency as well as use of analgesics up to two months after the intervention, however any difference attributed to the drug regimens by assessing of the trend of pain characteristics changes. Migraine is now identified as one of the most frequent disabling medical conditions experienced worldwide that more than 90% of the patients report an impaired function during migraine attacks, and half of them report severe disability requiring bed rest . The assAlthough there is no standardized procedure for GONB, the nerve is usually infiltrated by a local anesthetic or corticosteroid. Several studies suggested the efficacy of GON block in the treatment of migraine, cluster headache, and chronic daily headache. But, few of them were controlled and blinded. Despite a favorable clinical experience, little evidence exists for the efficacy of GON block in migraine treatment. Considering such a premise, we wished to evaluate the therapeutic efficacy of GON block in patients affected by migraine headaches.A randomized double-blinded controlled trial was conducted on 48 patients who suffering from migraine headaches and referred to neurology clinic of Golestan hospital in Ahvaz in 2013. These patients were considered to be included into the study by: age of 18 to 75 years, migraine history (with or without tenderness), at least one attack a week or MIDAS score greater than 11. The exclusion criteria were pregnancy or breast feeding, continuous headaches, opioid medications use, administration of prophylactic treatments for migraine within last two months, hypersensitivity to the drugs used in the study, local infection, cranial bone defect, chronic cluster headaches, chronic tension headaches, medication overuse headache, and fear from injection. According to inclusion criteria 52 patients entered into the study and 4 of them excluded because of not following the study protocol correctly or aggrevating headache without responding to GONB. This study was approved at 12/22/2012 by the Institutional Review Board of Studies in Human Subjects of ethics committee of Ahvaz JundiShapur University (Reference number: ETH-680). All patients provided a written informed consent prior to the enrollment.A syringe containing 1.0 mL of lidocaine 2%, 0.5 mL of either saline  or triamcinolone  was prepared for each patient. GONB were performed bilaterally. Using a 25 gauge needle, 1.5 mL was injected to each GON at the medial third of the distance between the occipital protuberance and the mastoid process. Patients were randomly assigned to either intervention or control groups and were blinded to the type of treatment they received. All patients were injected by a single physician who was not blinded to the type of treatment given. Demographic data were collected. Both groups received 20 mg tablets of Propranolol two times daily too. Patients were assessed prior to the injection, 2 weeks, 1 month, and 2 months after the injection by variables such as severity and frequency of pain, times to use analgesics and any appeared side effects. Headache severity was assessed on a 11 point scale. Analgesic use was measured as number of doses per week. Changes in symptom severity and other measured variables were compared between the two groups.Results were presented as mean ± standard deviation (SD) for quantitative variables and were summarized by frequency (percentage) for categorical variables. Continuous variables were compared using t test or Non-parametric Mann-Whitney U test whenever the data did not appear to have normal distribution or when the assumption of equal variances was violated across the two study groups. Categorical variables were, on the other hand, compared using chi-square test or Fisher’s exact test when more than 20% of cells with expected count of less than 5 were observed. The trend of the changes in study variables within study period was assessed using the Repeated Measure ANOVA test. For the statistical analysis, the statistical software SPSS version 21.0 for windows  was used. P values of 0.05 or less were considered statistically significant.The two intervention and control groups were matched in terms of mean age , and female gender distribution . The overall prevalence of occipital tenderness was 25.0% in intervention group and 20.8% in control group. As presented in In addition to assessing changes in pain severity, pain frequency, and times to use analgesics in total subjects, the trends of the changes in these variables were also assessed in the patients with or without occipital tenderness in both intervention and control groups. As shown in In the present study, the effect of GON blocking on migraine headaches were assessed by evaluating pain severity, pain frequency, and times to use analgesics. In this context, the changes in study variables were compared between the two groups including the intervention group which received triamcinolone and lidocaine and the control group received normal saline with lidocaine within eight weeks of study. Our study showed in both groups, a considerable decrease in three variables within two weeks from the injection time point in comparison to before the injection; however the trend of the changes in these variables were similar in both groups. On the other hand, our study showed that both drug regimens were similarly effective on reducing pain severity and frequency and on decrease of times to use an analgesic. Furthermore, the effects of these regimens persisted for 2 months after blocking of GON. Our findings were consistent with the previous studies. A research  showed tIn other assessment aspect of the study, interactive effects of occipital tenderness on the efficacy of GON blocking in reducing severity and frequency of pain, was shown that the trend of improving of these variables were similar in those with or without occipital tenderness and thus the presence of tenderness could not interact with the therapeutic effects of study interventions. In other words, the presence of occipital tenderness has no significant role in the outcome of GON blocking in migraine headaches.In conclusion, GON blocking with the two regimens including triamcinolone in combination with lidocaine or normal saline with lidocaine results in considerable reducing pain severity and frequency as well as use of analgesics up to two months after the intervention, although no significant differences attributed to the trend of changes of pain characteristics by one of the drug regimens. The presence of occipital tenderness has no effect on the changes of the trend of pain variables. According to our final findings, effects of the therapeutic interventions have been shown, but the superiority between one of the groups has not been indicated. Thus, in migraine status with MIDAS > 11 with no response or tolerance of common migraine treatments, GON blocking with lidocaine can be considered as a safe treatment approach.


To evaluate the parameters associated with significant gastrointestinal (GI) involvement in Henoch-Schönlein Purpura (HSP), and construct a scoring system for the identification of patients at high risk of gross blood in stools.Data for HSP patients hospitalized at each of seven institutes were retrospectively analyzed. Patients were divided into four groups according to the consequent severity of GI involvement. Identification of laboratory parameters at the time of admission were then used to differentiate the groups, and a scoring system to predict gross intestinal bleeding was constructed. Prognostic efficiency, correlation with the subsequent duration of abdominal pain, and association with manifestations excluding abdominal pain were also analyzed.An analysis of variance (ANOVA) test showed significant intergroup differences in white blood cell (WBC) count, neutrophil count, serum albumin, potassium, plasma D-dimer and coagulation factor XIII activity. A scoring system consisting of these parameters showed a good prognostic value for gross intestinal bleeding in a receiver operating characteristic (ROC) analysis, and a cut-off value of 4 points showed a sensitivity of 90.0% and specificity of 80.6%. The score was also correlated with the duration of abdominal pain after admission. A significantly higher score (s) was observed in patients presenting with nephritis, although the predictive value was poor.A scoring system consisting of generally available parameters was of use in predicting severe GI involvement in HSP patients. Although further study is needed, initial therapy in accordance with disease activity may be taken into consideration using this scoring system. Henoch-Schönlein Purpura (HSP) is a systemic, IgA-mediated, small vessel vasculitis which is common in children  1.5 ~ 2 mg/kg/day was administrated when the patient complained of unacceptable abdominal or joint pain.Patients were divided into four groups based on the severity of gastrointestinal (GI) involvement as follows; Group I: no abdominal pain, Group II: presence of abdominal pain, without intestinal bleeding , Group III: abdominal pain and positive for fecal hemoglobin, but not presenting with gross blood in the stools, and Group IV: abdominal pain with gross blood in the stools.U test was used to compare scores between patients with and without arthralgia and nephritis. The correlation between duration of abdominal pain after admission and score at admission was also examined using Spearman’s rank correlation coefficient.All analyses were carried out using the SPSS statistical software package, version 16.0 . Data are presented as the mean ± standard deviation (SD) or median and range for continuous variables, or as the percentage of patients showing a given categorical variable. For all analyses, a 2-sided probability value below 0.05 was considered to indicate statistical significance. Spearman’s rank correlation coefficient test was used to examine correlations among categorical parameters among the baseline characteristics and GI-involvement groups. A Kruskal-Wallis analysis of variance (ANOVA) was used to examine overall differences in laboratory data at the time of admission and other continuous variables among the GI-involvement groups. The data included WBC count, neutrophil count, hemoglobin, platelet count, serum concentration of albumin, aspartate aminotransferase (AST), alanine aminotransferase (ALT), lactate dehydrogenase (LDH), and C-reactive protein (CRP), prothrombin time (PT), activated partial thromboplastin time (APTT), plasma concentration of fibrinogen and D-dimer, coagulation factor XIII (fXIII) activity, serum concentration of antistreptolysin O antibody (ASO), IgA, complement C3, C4, total hemolytic complement (Ch50), sodium, and potassium. And age, days from symptom onset to admission, and days from abdominal pain onset to admission was also extracted. We then constructed a scoring model with which to identify severe GI involvement consisting of the parameters found to be statistically significant in the ANOVA analysis. A receiver operating characteristic (ROC) analysis was also carried out to examine the diagnostic utility of the constructed scoring model, and the Mann–Whitney During the study period, 140 patients were analysed, with 27 later excluded . Thus, 113 patients were included in the study. Table An ANOVA test showed the presence of significant overall differences in WBC count, neutrophil count, serum concentration of albumin, potassium, plasma level of D-dimer, and fXIII activity among the GI groups Figure A. ConstrIn the study population, 56 patients (49%) presented with abdominal pain, placing them into Group II ~ IV, and 43 of them (76%) received PSL at 1.5 ~ 2 mg/kg/day. The scores at the time of admission for the 43 patients who received PSL for abdominal pain were significantly correlated with the subsequent duration of abdominal pain after admission , it may also be useful for clinical follow up.The precise mechanism underlying the changes in the parameters comprising the scoring system has not yet been clarified. Kawasaki disease, another systemic vasculitis common in children, often presents as hyponatremia and hypoalbuminemia, especially in severe cases  reduces the intensity of abdominal pain and arthralgia in early HSP (Ronkainen et al. Of course, our study has several limitations. Our definition of GI group classifications was dependent on subjective symptoms and fecal examination; therefore, the classification criteria might require some improvement in terms of accuracy. Further, the proportion of patients with gross blood in stools was small. Last, our study was based on only a single cohort analysis. The survey of another cohort of HSP of HSP patients using our scoring system should help prove its validity. In addition, further large-scale or prospective studies are needed to overcome these limitations.The current study is the first report to the development of a scoring system for the identification of patients at risk for severe GI involvement on the basis of laboratory tests in the early phase of HSP.


P ≤ 0.05) in patients receiving FIB at 2 and 8 hours preoperatively. The timing of initial analgesia was also quicker in patients with FIB (25 compared to 40 minutes). FIB patients required fewer doses of systemic analgesia. The block was successful in 67% of patients. There were no complications. The implementation of EWTD, HAN, and shift-system and the reduction in the number of medical staff have increased the burden on emergency departments. This study demonstrates that FIB performed by junior doctors are not only safe and effective analgesia but also provide an opportunity for junior doctors to improve current clinical practice.Hip fractures are common and the incidence is expected to increase. Systemic analgesics, often prescribed to relieve pain after hip fractures, have huge side effects and can delay surgery. We analyse the role and efficacy of alternative forms of analgesia like fascia-iliac blocks (FIB) and assess the feasibility of a service delivered by junior doctors. 104 consecutive hip fracture patients were prospectively recruited and equally divided into cases (patients receiving FIB) and controls . Outcome measures included time of initial analgesia, total preoperative dose of analgesia, pain scores from admission to 24 hours preoperatively, and complications. The pain scores were significantly lower ( These figures are multifactorial and are in part due to the complications that occur after a hip fracture in a population group with significant comorbidities (median ASA grade 3) [About 75,000 hip fractures occur annually in the United Kingdom  often asgrade 3) .Hip fractures are painful and inadequately controlled pain can have significant physiological and psychological effects  such as Systemic analgesia including both opioids and nonsteroidal analgesia can have significant adverse effects especially in the elderly population due to age-related changes in pharmacokinetics and pharmacodynamics . FurtherFascia iliaca blocks (FIBs) provide regional pain relief and can address many of the issues surrounding traditional forms of analgesia. They have traditionally been a remit of anaesthetic professionals perioperatively targeting the lateral cutaneous, femoral, and obturator nerves found beneath the fascia iliac. While doctors in other specialities, such as the ED, have carried out the blocks, routine administration in clinical practice has been staggered with only 19% of patients receiving a peripheral nerve blockade for hip fracture . The reaThis study describes our experience of FIB applied in the emergency setting and compares outcomes to traditional systemic analgesia. In addition, we demonstrate the feasibility of junior orthopaedic and emergency doctors administering this form of pain relief at the point of need.A prospective case-control study was carried out over a six-month period in a large UK district general hospital involving the orthopaedic and emergency departments. This study was approved by the local audit committee.The patients were divided into two groups after informed verbal consent.All patients with hip fractures presenting to the ED from January to March 2012 received traditional forms of systemic analgesia according to the WHO pain ladder (controls).All patients with hip fractures presenting to the ED from April to June 2012 received FIB (cases).The absolute contraindications to FIB included patient refusal, bleeding diatheses, femoral grafts in the affected limb, and inflammation over the injection site and allergy to local anaesthetics.All junior doctors (foundation year 2—core training year 2) in the trauma and orthopaedics department were trained on administering FIB through a teaching presentation from an anaesthetic trainee, followed by supervised training in theatre by a senior anaesthetist. Once deemed competent by the consultant anaesthetist, juniors were permitted to administer a single FIB per patient during the day and night on-call period. Once a robust orthopaedic service delivery was in place, ED junior doctors were also trained and administered blocks allowing for an earlier use of the block. After receiving the block, codeine and paracetamol were prescribed on the “as-required” section of the drug chart. Regular systemic analgesia including paracetamol and opioids was commenced if operative intervention was delayed by more than 24 hours, if required.An 18 G Tuohy needle was used to administer a weight-dependant volume of 0.25% chirocaine (levobupivicaine) as per local anaesthetic protocol  under asT = 15 mins, monitoring was carried out by the clinician who performed the block and also included monitoring of blood pressure, heart rate, and oxygen saturation. Thereafter, monitoring was carried out in orthopaedic wards by healthcare professionals who received appropriate education and training about the project and how to elicit pain scores and their documentation. Block success was deemed as pain score <50% to the preblock score at 2 hours after block administration as per the standard of care agreed by the National Collaborative that a pain score should never exceed 50 per cent [Demographic data , Abbreviated mental test score (AMTS) and fracture classification (intracapsular/extracapsular) was recorded . Pain scper cent , 14. Thet-tests were used for two groups of variables and one-way analyses of variance (ANOVA) for more than two groups, followed by post-hoc Tukey analysis. For categorical data, Pearson's Chi-square test was used with statistical significance reached by a P value of <0.05.Analyses were carried out using the statistical package SPSS for Windows . For continuous data, Student's From January 2012 to June 2012, a total of 104 patients were included in the study. 52 received systemic analgesia as per the traditional methods (controls) and 52 patients received a FIB as soon as possible after radiological diagnosis (cases). Four patients were excluded from receiving a FIB, 3 due to a femoral graft in the affected limb and one due to severe aggressive dementia preventing safe administration. There were no complications and specifically no infections at the injection site. There were no wound infections postoperatively. The demographics of the two groups and their preoperative variables are shown in Hip fractures are painful and pain left untreated can result in a host of complications that may delay operative intervention and complicate hospital stay . Pain maP = 0.03) following blockade which continued for up to 8 hours (P = 0.01). While this study did not find any significant difference at 15 min, two previous studies have reported reduced pain scores at 15 min after block [This study demonstrates the beneficial effect of FIB, performed by junior doctors in ED, in management of pain in hip fracture patients. There was a significant reduction in pain scores at 2 hours    with mosThe beneficial effect of FIBs in patients with radiologically confirmed hip fractures is well known with several studies reporting a good outcome , 20–23, Mouzopoulos et al.  also fouT = 2 hr from preblock pain score based on the suggestion by Counsell [Our block success was 65%, which is on the lower site of the reported rates of 67%–96% , 23, 25.Counsell  and the Counsell .There are a number of ways to administer the FIB such as the loss of resistance (“2-pop techqnique”) that we used, USS guided blocks, or the nerve stimulators to locate the femoral nerve. USS guided blocks are not practical for all EDs due to training, timing, and resource limitations. The use of nerve stimulators has been shown to be no better than the loss of resistance technique. In fact the time for peripheral nerve stimulator block was significantly longer .While there are publications detailing the use of intradermal needles for the block, we used the blunt Tuohy needles which provide a further margin of safety and give a better “pop” sensation as the needles traverse the fascia, thereby reassuring the junior doctor that they are in the right compartment. As there are no reported studies comparing this technique, it would seem reasonable that this form of analgesia may be administered in the ED according to local resource and expertise available.The main limitations of this study are that the patients were not randomised, although the two groups were comparable . FurtherThe implementation of European Working Time Directive (EWTD), Hospital at Night, shift system has increased the burden on ED. As junior doctors are increasingly at the forefront of service delivery, administering FIBs is an essential skill to possess that can extend beyond anaesthetic training and the theatre environment. Furthermore, it encourages a more active role in pain management. This study demonstrates that the junior doctors without anaesthetic backgrounds can provide a rapid and effective pain service, supporting change to current clinical practice.With only 71.4% of hip fracture patients receiving their operation within the recommended 36 hours and the majority of delays occurring due to medical causes including complications of pain management , the admIn addition, utilising the expertise of an existing anaesthetic department could facilitate adequate training. Not only will this be time and cost effective but also will foster integrated learning between surgical, emergency, and anaesthetic specialities.


A pilot study has shown that real-time fMRI (rtfMRI) neurofeedback could be an alternative approach for chronic pain treatment. Considering the relative small sample of patients recruited and not strictly controlled condition, it is desirable to perform a replication as well as a double-blinded randomized study with a different control condition in chronic pain patients. Here we conducted a rtfMRI neurofeedback study in a subgroup of pain patients – patients with postherpetic neuralgia (PHN) and used a different sham neurofeedback control. We explored the feasibility of self-regulation of the rostral anterior cingulate cortex (rACC) activation in patients with PHN through rtfMRI neurofeedback and regulation of pain perception.Sixteen patients (46–71 years) with PHN were randomly allocated to a experimental group (n = 8) or a control group (n = 8). 2 patients in the control group were excluded for large head motion. The experimental group was given true feedback information from their rACC whereas the control group was given sham feedback information from their posterior cingulate cortex (PCC). All subjects were instructed to perform an imagery task to increase and decrease activation within the target region using rtfMRI neurofeedback.Online analysis showed 6/8 patients in the experimental group were able to increase and decrease the blood oxygen level dependent (BOLD) fMRI signal magnitude during intermittent feedback training. However, this modulation effect was not observed in the control group. Offline analysis showed that the percentage of BOLD signal change of the target region between the last and first training in the experimental group was significantly different from the control group’s and was also significantly different than 0. The changes of pain perception reflected by numerical rating scale (NRS) in the experimental group were significantly different from the control group. However, there existed no significant correlations between BOLD signal change and NRS change.Patients with PHN could learn to voluntarily control over activation in rACC through rtfMRI neurofeedback and alter their pain perception level. The present study may provide new evidence that rtfMRI neurofeedback training may be a supplemental approach for chronic clinical pain management. Postherpetic neuralgia (PHN) is a common type of neuropathic pain characterized as a sharp, burning or stabbing pain following herpes zoster infection . It can Biofeedback is one of the most prominent behavioral approaches in which patients learn to voluntarily control over their bodily reactions through the feedback of physiological processes, such as brainwaves, muscle tone, skin conductance, heart rate and pain perception . NeurofeThe first rtfMRI neurofeedback study concerning pain modulation demonstrated that individuals could gain voluntary control over activation in the rostral anterior cingulate cortex (rACC), which was putatively involved in pain processing, leading to control over pain perception . HoweverIn this work, we aimed to explore whether patients with PHN were able to up and down regulate their rACC BOLD signal through rtfMRI neurofeedack, and whether the regulation would alter pain perception level. We predicted that our results would be consistent with previous rtfMRI studies concerning pain management , 18–19. The study was conducted in accordance with the principles of Declaration of Helsinki  and appr16 right-handed patients with PHN were enrolled from the Pain Management Department of People’s Hospital of Zhengzhou University, China. The diagnosis was made by a senior doctor in pain management (LJ.X) according to the International Association for the Study of Pain (IASP) criteria . ExclusiA randomized, double-blind, sham-controlled between-subject design was utilized. (1) Experimental group: 8 patients  were given true feedback information from their rACC BOLD signal. (2) Control group: 8 patients  received identical training to the experimental group, but using rtfMRI information derived from the posterior cingulate cortex (PCC). PCC has been implicated as an area not involving in pain processing . All patBefore MRI scanning, all patients were given a detailed explanation about the purpose of the study. Then a sample scrolling line graph representing BOLD activation  was shown and explained to them clearly . The patThe paradigm was consisted of two fMRI tasks . First, ROIs for the neurofeedback were individually selected during the localizer task based on the activation observed within rACC using the pain—rest contrast. Then, a squared ROI with the side length of 1 cm in a single slice was positioned manually . Such ROTo quantify the pain perception level of each patient and to assess the therapeutic effect of the rtfMRI neurofeedback, a 11—point numerical rating scale (NRS) ranging from 0 (not painful) to 10 (the most painful) was adopted . The patMR imaging was conducted at the Medical Imaging Center of People’s Hospital of Zhengzhou University. The rtfMRI neurofeedback system was composed of a 3.0T MRI scanner , Turbo-Brain Voyager (TBV) Version 1.1  and a Visual Stimulation System for fMRI  . An in-h2, matrix size = 64 × 64, flip angle = 90°, number of volumes = 153. (2) the rtfMRI neurofeedback training run using the same sequence and parameters as the localizer task, except the number of volumes was increased to 303. (3) A high-resolution anatomical scan was acquired for image normalization using a three dimensional fast spoiled gradient (3D FSPGR) sequence. The parameters were: TR = 8.2 ms, TE = 2.26 ms, in-plane matrix resolution = 256 × 256, slices = 200, field of view = 256 × 256 mm2, flip angle = 12°.A standard 8-channel birdcage head coil was used, along with restraining foam pads to minimize head motion and to diminish scanner noise. MR scanning was performed in the following order: (1) A localizer task-fMRI scanning using GRE-T2* EPI sequence. The following EPI imaging parameters were: TR (repetition time) = 2000 ms, TE (echo time) = 30 ms, slice thickness = 4.0 mm with the interslice gap of 0 mm, slices = 33, field of view = 220 × 220 mmFunctional imaging data was preprocessed and statistically analyzed on-line using TBV within one TR . Preprochttp://www.fil.ion.ucl.ac.uk/spm). Functional data was spatially realigned, co-registered to the anatomical data, normalized and smoothed (8 mm kernel). Then group analysis was performed based on GLM using the block design. Family-wise error (FWE) corrected values of p<0.05 were considered as significant.Off-line data analysis was performed with Statistical Parametric Mapping (SPM 8) (http://afni.nimh.nih.gov/). As we were only concerned about the final modulation effect of rtfMRI neurofeedback, only the first and last training run of each patient was selected for the signal change analysis. The rate of BOLD signal change p was computed as:block is the average signal intensity of the task block which included all up-regulation or down-regulation blocks, mean is the average signal intensity of the base contrast [p was calculated as Δp = Plast-Pfirst. Two–tailed one-sample t-tests were conducted to assess the difference of Δp comparing with 0 during up and down regulation separately. One-tailed two-sample t-tests were conducted to assess the difference of Δp between the experimental and control groups. All tests were conducted using SPSS 17.0 . The critical threshold for significance was set at p<0.05.ROI analysis was performed with the Analysis of Functional NeuroImages (AFNI) analysis package  in the control group were eliminated due to the large head motion. Finally, data from 14 patients  were analyzed. 10 patients completed two training runs, 2 patients completed three training runs, and 2 patients completed four training runs. Both groups did not differ in gender proportion, mean age, duration of PHN, NRS baseline score and training runs .In addition, to assess the difference of pain localization in both groups, the pain regions complained by each patient was classified into 4 main anatomical regions: that craniofacial region, cervix and upper limb, thorax, abdomen. Fisher's exact test was performed, and the result showed that both groups did not differ in the distribution of pain location (P > 0.05).Through the course of training, 6/8 patients in the experimental group were able to learn to control the fMRI activation in their own rACC. An uprated line of BOLD activation went regularly up and down as the study design . AccordiThe functional localizer revealed significant activation within the rACC, the Basal Ganglia (BG), the Inferior Frontal Gyrus (IFG), the Premotor Cortex (PMC), the Inferior Temporal Gyrus (ITG), the Superior Temporal Gyrus (STG), and the precuneus. All these regions were involved in pain processing .p) between the last and first training runs was assessed using two tailed one-sample t-tests (comparing activation to 0). The values of Δp during up and down regulation were both significantly different than 0 (t(7) = 4.259; p < 0.01 for up regulation; t(7) = -2.51; p < 0.05 for down regulation). Also there was a significant Δp between experiment group and control group (t(12) = 3.39; p < 0.01 for up regulation; t(12) = 7.01; p < 0.05 for down regulation). In control group, no significant difference of Δp between the last and first training runs was observed during up regulation (t(5) = -1.44; p > 0.05) and down regulation (t(5) = 0.51; p > 0.05)  . These rThe mean change of NRS for both groups was listed in In this study, we investigated the feasibility of training patients with PHN to learn to increase and decrease the level of activation of rACC using rtfMRI neurofeedback. The results demonstrated that given appropriate directed training based on rtfMRI neurofeedback information, patients with PHN could learn to up and down regulate the BOLD activity of rACC, leading to alter their pain perception within a short time of training. Moreover, using a strict control condition, our results demonstrated that this training effect of rtfMRI neurofeedback was due to the target rACC region other than a placebo effect. Our study may provides new evidence that rtfMRI neurofeedback training may be a possible supplemental approach for pain management.It has been widely accepted that pain was a brain-based phenomenon . NeuroimThe online analysis on TBV showed that 2 out of 8 patients in the experimental group did not succeed in regulation. This was consistent with one study exploring the effect of training in chronic tinnitus, in which 1 of 6 patients could not succeed . In a siChoosing an efficient mental imagery strategy for self-regulation is challenging for rtfMRI neurofeedback training. Earlier conventional wisdom suggests that providing a well-known explicit strategy to the subject would enable more efficient self-regulation, and that implicit mental imagery strategies would be time-consuming in the harsh and expensive MR environment . Hence wSeveral previous studies have shown that learned control of brain activity would lead to behavioral effects that are specific to the functional role of the target brain area , 32. deCThe mechanism underlying self-regulation and corresponding behavior change has been unclear. Until now, few studies have tested specific theoretical hypotheses about the mechanism of operant and cognitive control of neural activity. At the brain level, rACC is a specific area linked to attention , emotionAs many confounding factors may affect the effect of rtfMRI neurofeedback training, selecting an optimal control task is essential for determining whether the feedback signal is necessary for learning to regulate brain activation, compared to the effects on brain activation produced through repetitive training using simple instructions alone . HoweverThe following limitations should be taken into account when interpreting the current results. First, due to the small sample size in this work, the present results should be interpreted with caution. It is desirable to replicate the study with larger patient samples and other pain conditions, although the requirement of a good and voluntary corporation for rtfMRI neurofeedback is a challenge for recruiting more patients for the study. Second, a transfer run was not included for the ethical consideration and to focus on regulation training. Next we will conduct a study exploring the lasting effect of rtfMRI neurofeedback with such a design. Third, the complex confounding effects of PCC as the control region should be reconsidered in our study. On the one hand, unsuccessful sham control may induce frustration or other negative emotion. Thus more cognitive or emotional processes may be involved and interfere with the regulation. On the other hand, PCC is one of the key nodes in the default mode network (DMN) and usually deactivated during cognitively tasks. It may prevent the PHN patients from successfully up-regulating brain activation. Thus it is meaningful to conduct a study selecting other region like the centrum ovale. Fourth, a manual stimuli delivery was adopted for functional localizer task, there might be a certain amount of variability between stimulation blocks. Last, the individual training runs in our study were not identical, and only the first and the last runs were analyzed. The difference in training may confound the true effect of neurofeedback. As a matter of fact, we are looking for a chance to conduct a more rigorous study investigating the correlations between the regulation effects and training runs.In conclusion, our study demonstrates that patients with PHN could voluntarily regulate activity of their rACC through rtfMRI neurofeedback training. As a result, their pain perception changed significantly. In contrast, patients with PHN in control group receiving neurofeedback information from PCC could not control over rACC and pain perception level. Our study suggests that rtMRI neurofeedback training may be a supplemental approach for pain relief of chronic clinical pain in short time.S1 FigA) The framework of rtfMRI neurofeedback system. The system was composed of a 3.0 T MRI scanner, data processing workstation and a displaying device. B) The interface of Turbo-Brain Voyager (TBV). The scrolling line of ROI in the top right was displayed to participants in scanner. The head motion parameters in the down right may help control the quality of fMRI data.(TIF)Click here for additional data file.S1 TableH = hemisphere, R = right hemisphere, L = left hemisphere, rACC = rostral anterior cingulate cortex, BG = Basal Ganglia, IFG = Inferior Frontal Gyrus, PMC = Premotor Cortex, ITG = Inferior Temporal Gyrus, STG = Superior Temporal Gyrus, TAL = Talairach coordinates, all values were family-wise error (FWE) corrected (P < 0.05).(DOCX)Click here for additional data file.


In familial aTTR amyloid polyneuropathy (FAP) cardiac involvement is of major prognostic value. Two approaches using radionuclide imaging proved relevant in the assessment of aTTR-related cardiac amyloidosis: detection of amyloid deposits with disphosphonates (DPD) and of sympathetic denervation with MIBG. The study aimed to compare the respective value of both approaches in patients with aTTR-FAP with suspected cardiac involvement.We prospectively included 76 consecutive patients identified from the database of the French National Reference Center for Amyloidosis with genetically proven aTTR-FAP ≥12 mm: 52%; left ventricular ejection fraction: 63±10%). They underwent both MIBG and DPD scintigraphy in a delay <3 months. For DPD SPECT, acquisitions were performed 3 hours after tracer injection. Cardiac uptake was visually scored as present or absent and quantified by the ratio between 3D isocount volume of interest generated over the myocardium and a standard volume in lung (H/L). For MIBG, heart-to-mediastinum ratio (HMR) was calculated on planar acquisitions performed 4 h after tracer injection. Cardiac MIBG was classified as normal, mildly, moderately, or severely abnormal.The delay between DPD and MIBG 6±12 days. DPD was abnormal in 30 patients (39%) and MIBG in 50 patients . When MIBG was normal (n=26), BS was normal except for 1 patient. When MIBG was abnormal (n=50), BS was normal in 21 patients (42%). The uptake of DPD increased with the denervation score . In patients with a previous domino liver transplantation (n=10), the overall pattern was similar. In asymptomatic patients (n=31), all those with a normal MIBG (n=17) had a normal DPD; MIBG was abnormal in 45% (n=14), 50% had a normal DPD. In addition, HMR was greater  and H/L was lower  compared to symptomatic patients.In patients with suspected cardiac involvement of aTTR-FAP, MIBG was abnormal more frequently than DPD. In particular, DPD abnormalities are delayed compared to MIBG since it was abnormal only when denervation was moderate or severe. In the group of asymptomatic patients, MIBG was abnormal in 45% of patients, and only half of those with cardiac denervation had a positive BS. This suggests that innervation abnormalities as seen with MIBG are more frequent and earlier than significant amyloid deposits as seen with Diphosphonates.


In this study, we tried to show the efficacy of Intraperitoneal dexamethasone on relieving shoulder pain after gynecologic laparoscopy.In this double-blind randomized clinical trial, 63 patients who werecandidates for gynecologic laparoscopy were included. At the end of the procedure patientsrandomly received 16 mg dexamethasone (n=31) or placebo (n=32) intraperitoneally. Visualanalogue scale (VAS) was used for clinical evaluation of pain severity during 24 hours afterlaparoscopy . A physician, who was not aware whether patients were treated with drug or placebo, evaluated the patients.The severity of pain in the dexamethasone group within 0, 2, 4, 8, 12, 24 hoursafter procedure was significantly less than in the placebo group (p<0.001). The averageconsumption of opioids as analgesic/ sedative in the placebo group was more than thedexamethasone group (p=0.025).Findings of this study show that the prescription of 16 mg of dexametha-sone (single dose) in the peritoneal cavity may significantly reduce the severity of painafter Laparoscopy in comparison with placebo and may decrease the need for narcoticsas pain relief (Registration Number: IRCT201105306640N1). Today, laparoscopy is one of the most commonmethods of diagnosis and treatment used all overthe world. It has various indications in abdominaland pelvic surgeries. Laparoscopic surgery hasmany advantages: patients recover very quicklythus requiring a shorter stay in hospital -3.MoreoInterestingly, post-laparoscopic pain is verydifferent from that of post-laparatomy. In fact,the pain after laparotomy is somatic pain;whereas, patients experience visceral pain afterlaparoscopy . ShouldeRecently, the injection of local analgesics at the time of laparoscopic surgery, in order to relieve postoperative pain has become more common. One of such methods is the intra abdominal injection of analgesics such as lidocaine and bupivacaine -13. HoweSince steroids have been used for reducing inflammation, they may be considered as alternatives for relieving pain. Dexamethasone is a strong long acting Glucocorticoid and it is widely used after surgery , 15. It Recently, it has been established that higher doses of dexamethasone and other glucocorticoids are effective in relieving postoperative pain in foot surgeries, breast surgeries, laparoscopic cholecystectomy and spinal column surgeries -24.Although, the effects of dexamethasone have not yet been established, it is probable that pain relief is caused by the inhibition of prostaglandins production . There is an other theory which states that dexamethasone acts by reducing the amount of 5-Hydroxytryptamine (5HT) which is returned into the central nervous system or by increasing the permeability of the blood-brain barrier for serum proteins. So far, according to available information, there is not a published study with high quality methodology about effectiveness of intraperitoneal dexamethasone. However, intravenous dexamethasone has been previously used for relieving nausea after laparoscopy -27.In this study, we compare the effectiveness of intraperitoneal dexamethasone with placebo in patients which have undergone gynecologic laparoscopy in a double-blind randomized clinical trial.This study is a double blind randomized clinical trial that has been approved by the Ethical Committee of Tehran University of Medical Science. We enrolled women who had undergone gynecologic laparoscopy in Arash Hospital during 2009-2010. According to the inclusion criteria for participation in this study, only women between 18-70 years old with gynecologic indication for laparoscopy were included. Furthermore, since the general condition of patients was important and in order to allow the questions of investigators to be answered, the patients were allocated to groups I or II according to the American Society of Anesthesiologists (ASA) physical classification system. Patients with a history of diabetes mellitus, abdominal surgery, drug reaction to dexamethasone and those previously treated with steroids were excluded from the study. All the patients signed a written consent form after being made aware of the full procedure before participating in this study. A gynecologist gathered the basic information needed for this study such as age, fertility condition , weight, height, body mass index (BMI) and the type of laparoscopic surgery they had undergone from each patient before assigning them to one of the two groups.The patients were then divided to two groups, and those in the first group received intraperitoneal dexamethasone while those in the second group received placebo. Block randomization method with four blocks was used to assign the patients into groups. The treatment option for the groups was selected by chance by drawing lots. At the end of selection, the number of people who had been selected in each block were equal. All patients underwent anesthesia. At the end of the surgery, the surgeon injected 16 mg of dexamethasone into the peritoneum of patients from the first group and 16 cc of normal saline as placebo to patients in the second group.Patients were asked about severity of shoulder pain within 2, 4, 8, 12, 24 hours after laparoscopy. Severity of pain was assessed by visual analogous scale (VAS) method. In this method, the intensity of pain was classified from zero to 10. Painlessness was scored as 0 and the maximum severity of pain that patients experienced was scored as 10.According to VAS method, patients reported their severity of pain within mentioned periods. 25 mg of pethidine that was diluted in 10 cc normal saline was injected intravenously. This dose was repeated every 4 hours according to patients' demand. The total amount of pethidine injected within 24 hours after surgery was recorded for each patient.Collected data were analyzed by SPSS 13. Quantitative data were shown as mean and standard deviation and qualitative data were shown as frequency. Chi-square was used to compare the two groups of qualitative data and the ttest was used to compare quantitative data in two groups if our distribution was normal. When our distribution was not normal, nonparametric tests were used. P-value less than 0.05 was considered as significant.In this study, 63 patients in two groups were evaluated. The first group included patients who received intraperitoneal dexamethasone (31 patients) and the second group included patients who received placebo (32 patients). Patients were aged between 18-47 and according to our findings, there was no significant difference between the two groups regarding age, BMI and the physical condition based on ASA. According to the results there is no statistically significant difference between the two groups in the mean time of Laparoscopic surgery which is 51.1 ± 35.8 minutes in the first group (dexamethasone) and 53.7 ± 35.6 minutes in the second group.As mentioned above, the patients' pain severity increased in the placebo group and after 8 hours it started to decrease; whereas, in the dexamethasone group, the average pain severity was less than 3. In the dexamethasone group, during recovery and 2, 4, 8, 12, 24 hours after surgery, the pain severity was significantly less than in the placebo group. This difference is less than other stages of the study after recovery. Also, passing time and other general factors such as age, BMI and long-time laparoscopic surgery may influence the patient’s pain severity; so we used analysis of the variance of repeated measurements to try and determine whether these factors influence pain severity.The results of this study show that reduction of pain severity in dexamethasone group is independent from other factors and dexamethasone can relieve the pain severity by itself (p<0.001). The first time of prescribing opioid as an analgesic in dexamethasone group and placebo group was after 1 hour. Generally, 83% of patients treated with dexamethasone and 78% of patients treated with placebo requested an analgesic during one hour after surgery. There are no statistically significant differences regarding the first time of demanding analgesics.The average amount of opioid (pethidine) administered was 27.5 ± 7.6 mg in the dexamethasone group and 35.9 ± 18.9 mg in the placebo group. The prescribed amount of opioid as an analgesic in the placebo group was significantly more than that used in the dexamethasone group (p=0.025). We found no complications such as wound infection and delay in wound healing during the period of investigation.The main goal of designing this study is to answer the question of whether a single dose of dexamethasone injected into the peritoneal cavity can relieve the pain severity after laparoscopic surgery or not? We believe this to be a novel investigation seeing as no similar studies have previously been conducted. The results of this study, show that injection of dexamethasone in the peritoneum after laparoscopic surgery can significantly relieve postoperative pain. Also, the patients treated with dexamethasone requested fewer narcotics compared to the patients treated with the placebo.Prevention and relief of postoperative pain and its complications such as nausea and vomiting are important concerns in the care of patients after laparoscopy. In addition, this plays an important role in the improvement of patients´ general condition . For conAs previously mentioned, the mechanism of pain after laparascopy is completely different from the pain after Laparatomy. Pain after Laparotomy is a somatic pain but Laparoscopy is followed by a visceral pain , 30. SomIn the recent years local analgesics such as lidocaine and bupivacaine have been commonly used to relieve postoperative pain , 26. IntDexamethasone as a corticosteroid has been widely used for the treatment of some complications such as nausea and vomiting and has been effective.Although the analgesic effects of corticosteroids have been shown in the clinical settings, it has not yet been determined whether it can be effective in the reduction of postoperative pain or not?In this study, we injected dexamethasone directly to the inflamed location and we succeeded to show that dexamethasone can relieve postoperative pain and reduce the need for opioids. Nevertheless, the question still remains whether or not the systemic (intravenous) dexamethasone can cause such effects?Although applied amounts of dexamethasone has no serious side effects and it has been widely used, if higher doses are administered some side effects may be experienced such as gastrointestinal bleeding, increasing infection rate and delayed wound healing.In a meta-analysis of 52 investigations 15-30 mg/kg of methylprendnisolone was prescribed for 1900 patients. No significant difference was reported regarding serious side effects in comparison with the control group . Some of


Mechanical foot pain is a syndrome in which local pain is associated with musculoskeletal tissues, occurring as a result of mechanical stress. Recent research has indicated that bone marrow lesions (BML) in the knee are associated with mechanical knee pain and increased forces, and that changing the forces within the knee can alter the pattern of BML. As foot orthoses are thought to act by modifying abnormal foot motion and internal distribution of forces, the aim of this study was to explore whether foot orthoses can modify volumes and patterns of BML in patients with mechanical midfoot pain.Forty-two patients were recruited from the Leeds Musculoskeletal Podiatry Service with mechanical midfoot pain and presence of BML as identified on 0.2T extremity magnetic resonance (MR) imaging. Patients were randomised to receive either (i) and active intervention, a pre-fabricated foot orthoses  or (ii) a sham device, which consisted of 4mm of flat, compressed, closed-cell polyethelene foam. A group of age matched controls  was also recruited (n=41). Outcome data included patient reported outcomes and high resolution MR images, captured using a 3T scanner. Patients were seen at 6 weeks, and then three months after receiving the orthoses, when measures were repeated.As this was an exploratory study, no formal inferential analysis was undertaken. At baseline, there were some incidental BML identified in the control group (n=3 lesions), the mechanical foot pain group demonstrated 108 BMLs, with the most common sites being the cuneiforms and the second metatarsal. After 6 weeks, there was a greater reduction in the mean visual analogue pain scale in the active intervention  compared to the sham  intervention group, and in the active group (pre-formed devices) there was a further reduction in pain  from 6 to 12 weeks that was not shown in the sham group . By 3 months, the mean BML volume was decreased by 26% in the pre-fabricated orthoses group, compared to a reduction of only 4% in the sham group. Furthermore, BML patterns were altered systematically in the pre-fabricated orthoses group with a greater reduction in medial bones with BML, while the sham group remained relatively unchanged.Our data are consistent with other published research reporting that patient reported outcomes are improved in patients wearing foot orthoses. We also found a higher frequency of BML in people with mechanical foot pain. More importantly, the MRI data indicate that with the use of prefabricated orthoses we were able to reduce BML volume  and to alter systematically the pattern of BML in the tarsal bones. These results suggest that functional foot orthoses do have an effect on the bone stress continuum and provide further support to the hypothesis that functional orthoses act through internal distribution of forces within the foot.


To determine the clinical characteristics of Continuous Neuropathic Orofacial Pain in patients that suffer Persistent Idiopathic Facial Pain (PIFP), Painful Post-Traumatic Trigeminal Neuropathy (PPTTN) or Burning Mouth Syndrome (BMS) and to describe their treatment.A retrospective observational study was made, reviewing the clinical history of the patients diagnosed with Continuous Neuropathic Orofacial Pain between 2004 and 2011 at the Orofacial Pain Unit of the Master of Oral Surgery and Implantology of the University of Barcelona and at the Orofacial Pain Unit of the Teknon Medical Center of Barcelona.The average age of the patients with Continuous Neuropathic Orofacial Pain was 54.5, with a clear female predominance . Of all patients, 60.9% (n=14) were suffering a PIFP, 21.7% (n=5) had a BMS and 17.4% (n=4) were presenting a PPTTN. The pain quality described by the patients with Continuous Neuropathic Orofacial Pain was oppressive , widely represented by patients with PIFP, and burning  being the only quality that described patients with BMS. The treatment carried out with the patients was only pharmacologic. The most used drugs for the treatment of PIFP and PPTTN were clonazepam  and amitriptyline . However, a 55.5% (n=10) of the patients with PIFP or PPTTN required the association of two or more drugs for a correct pain control. All the patients with BMS responded satisfactorily to clonazepam.Continuous Neuropathic Orofacial Pain is a little known condition among the general population, physicians and dentists. This favors a late diagnosis and inaccurate treatments which entail unnecessary suffering. It is important to inform both the general population and health professionals concerning this painful condition. Key words:Continuous neuropathic orofacial pain, persistent idiopathic facial pain, painful post-traumatic trigeminal neuropathy, burning mouth syndrome, atypical odontalgia. International Association for the Study of Pain, neuropathic pain is initiated or caused by a primary lesion or a nervous system dysfunction  and continuous neuropathic pain. Continuous neuropathic pain differs from episodic neuropathic pain by presenting periods of high and low intensity without complete remission. The diagnostic key is the absence of a somatic source of pain ,3. This International Classification of Headache Disorders of the International Headache Society (IHS) includes PIFP, PPTTN and BMS in the group Painful cranial neuropathies and other facial pains (group 13)  . Okeson  . PPTTN is a traumatic neuralgia, generally due to a traumatic neuroma formation after a surgical procedure or trauma . The diaFinally, Burning Mouth Syndrome is an intraoral burning or dysaesthetic sensation on the tongue, lips, gingiva and/or oral mucosa, recurring daily for more than 2 hours per day over more than 3 months, without clinically evident causative lesions. Oral mucosa is of normal appearance and clinical examination including sensory testing is normal ,8,9.The objective of this study is to determine the clinical characteristics of Continuous Neuropathic Orofacial Pain in patients that suffer PIFP, PPTTN or BMS and to describe their treatment.A retrospective observational study was made by means of reviewing the clinical records of patients diagnosed with Continuous Neuropathic Orofacial Pain seen between 2004 and 2011 at the Orofacial Pain Unit of the Master of Oral Surgery and Implantology of University of Barcelona and the Orofacial Pain Unit of Teknon Medical Center of Barcelona. The study design was approved by the Research and Ethics Committees of University.International Classification of Headache Disorders of the International Headache Society. The patients with incomplete protocols were excluded.The patients included were under clinical diagnosis of PIFP, PPTTN and BMS, according to group 13 of the The variables collected were divided in three categories:- Patient variables: gender, age at the moment of diagnosis and the presence of systemic disease or psychological/psychiatric disorders.- Pain variables: clinical diagnosis, quality, intensity, anatomical location, duration, pain aggravators and relievers, the possible trigger, time of evolution to clinical diagnosis and the concomitant symptoms of pain.- Therapeutic variables: prescribed drug treatment and its side effects.The patient data and the pain characteristics that were used for the statistical study were registered during the first visit to the Orofacial Pain Units. All the patients were subjected to the same protocolized clinical history.The quality of pain was registered by showing the patients a list of descriptive adjectives: oppressive, electrical, burning, shooting, sharp and throbbing. In order to register the pain intensity, the patients were asked to classify it as low, moderate or intense.Microsoft Access for Windows was used for data collection. A descriptive analysis was performed with the Statistical Package for the Social Sciences for Windows .The study sample consisted of 23 patients with Continuous Neuropathic Orofacial Pain, with a clear female predominance . The average age of patients was 54.5 (range 34-70). Of all patients, 60.9% (n=14) were suffering a PIFP, 21.7% (n=5) had a BMS and 17.4% (n=4) were presenting a PPTTN. The mean evolution time, namely the period between onsets of the symptoms and diagnosis, was 28.1 months (ranging from 0.5 to 96).PIFP were located at the maxilla in 64.3% (n=9) of cases, at the infraorbital area in 28.6% (n=4) and one case  at the intermenton (chin) zone. The location of PPTTN was 50% (n=2) on the inferior lip, and 25% (n=1) on the intermenton zone and the infraorbital zone. All the BMS were located in the tongue , although three patients also referred having burning pain in the palate, oral mucosa and lips.The pain quality described by the patients with Continuous Neuropathic Orofacial Pain was (n=23): oppressive , widely represented by patients with PIFP, burning , being the only quality that described patients with BMS, electrical , sharp , throbbing  and 1 patient with PPTTN referred shooting pain . The 39.13% (n=9) of cases reported two or more types of pain quality.The most prevalent pain intensity was moderate , followed by low  and severe intensity . Variations of pain intensity were described by 34.78% (n=8) of participants.Stress increased the pain intensity for 34.8% (n=8) of cases and 43.5% (n= 10) of the patients presented other systemic diseases and psychiatric/psychological disorders related or not to the chronic pain.All the patients with PPTTN (n=4) reported that their pain was triggered by a surgical procedure on the affected nervous zone and all the patients presented sensory alterations on the affected area . The 71.43% (n=10) of patients that suffered a PIFP reported a pain trigger, for instance a surgical procedure, depression or lip hair waxing. No patients with PIFP presented sensibility alterations on the painful area. The patients with BMS did not report any pain triggering.The treatment carried out with the patients was only pharmacologic. We divided the patients into two therapeutic groups. The first group describes the treatments performed for patients with PIFP and PPTTN. Patients with BMS comprised the second group.PIFP and PPTTN (n=18) patients may often respond similarly to the same drug treatment, interindividual differences being essential. Association of two or more drugs for the correct pain control was required for 55.5% (n=10) of these patients. The 50% (n=9) of cases were treated with clonazepam, 44.44% (n=8) received amitriptyline and 33.33% (n=6) duloxetine. Besides, venlafaxine , nortriptyline , pregabalin  and gabapentine  were used. The drug most associated with the other ones was clonazepam. The drug of choice that we first used in all the patients of this group was amitriptyline. The most described side effects were drowsiness (n=2), fatigue (n=3), xerostomia (n=4), cardiovascular (n=2) and sensory alterations (n=2), among others.All the patients with BMS (n=5) responded satisfactorily to treatment with clonazepam, at doses of 1-1.5 mg/day. The described side effects were somnolence (n=2), fatigue (n=1) and aggressiveness (n=1).To date, the prevalence of PIFP in the general population is still unknown. According to this study, a higher prevalence of PIFP has been found among women. The highest prevalence of cases reported by literature is around the fourth decade of life, unlike in our sample that appears in the fifties ,7,10. AlAccording to this work, some studies report that molars and premolars are the most frequently involved teeth and that the maxilla is more often affected than the mandible ,16,17.Regarding to PPTTN, it has not been described to have a gender tendency. All the patients have sensory alterations  and relate that the start of pain was a surgical procedure like dental implant surgery ,4,18. ReAccording to the available literature, tricyclic antidepressants (TCAs) seem to be the most effective medication for the treatment of neuropathic chronic orofacial pain ,19-21. TIn agreement with these findings, the most used drugs in our patients diagnosed with PPTTN and PFIP were clonazepam and amitriptyline. The drug of choice that we first used in all these patients was amitriptyline. However, in a third of patients with PPTTN and PIFP, we had to prescribe two or more drugs to achieve an adequate pain control.BMS is a painful intraoral sensation characterized by the burning sensation of the tongue, lips, gingiva and/or oral mucosa . All theet al. (Clonazepam is the most commonly reported drug in literature to treat BMS ,26,27. Tet al. . In our A recent study by Yang and Huang  proposesContinuous neuropathic orofacial pain is a little known condition among the general population, physicians and dentists. Unfortunately, this favors a late diagnosis and an inaccurate treatment which entails unnecessary suffering for the patient. It is important to inform the general population and health professionals concerning this painful condition.


Subacromial impingement is a common cause of shoulder complaints in general practice. When the initial treatment with acetaminophen and low dose Non Steroidal Anti Inflammatory Drugs fails, triamcinolone acetonide injections are commonly used. Triamcinolone acetonide injections are effective at four to six weeks. Little is known about the pain relief effect of triamcinolone acetonide injections in the first days after injection and the effect of repeated injection. In this study we investigate the effect of triamcinolone acetonide injections compared to hyaluronic acid and NaCl injections using a pain diary.159 Patients recruited for an RCT comparing the effect of subacromial injections of triamcinolone acetonide, hyaluronic acid and sodium chloride (NaCl) were used in this study. They were blinded for their treatment and could receive up to three injections. Primary outcome consisted of the patient perceived pain on a VAS score recorded on a daily basis during 21 days following injection. Secondary outcome consisted of the amount of taken escape medication following injection and adverse effects.All patients received the first injection. 150 patients also received the second and third injections. 97% Of the paper and pencil pain diaries were returned for data analysis.The triamcinolone acetonide group showed the largest decrease in pain on the VAS scores after injection compared to the hyaluronic acid and NaCl group in the first week after injection. The reduction in pain was best achieved after the first injection, the second triamcinolone acetonide injection showed a further reduction in pain. The third triamcinolone acetonide injection only showed a slight improvement in pain reduction.In this study we could show a booster effect in pain reduction after repeated triamcinolone acetonide injection. The triamcinolone acetonide group showed a faster reduction in pain after injection compared to the hyaluronic acid and NaCl group. The effect was best seen after the first and second triamcinolone acetonide injection, it is therefore questionable whether it is necessary to repeat triamcinolone acetonide injections more than two times.ISRCTN51511455. Registered 20 December 2005The online version of this article (doi:10.1186/1471-2474-15-352) contains supplementary material, which is available to authorized users. Shoulder complaints are frequently encountered in General Practice , 2, of wA few studies have shown improvement in pain and function following the subacromial injection of hyaluronic acid alone –12.Hyaluronic acid is thought to serve as a lubricant  and is rSeveral studies have investigated the side effect of corticosteroid injections, in these studies only few side effects are described provided injections are not repeated too often at the same site . Some anLittle is known about the effect on pain reduction after repeated corticosteroid injection , 21.This study was part of a randomized clinical trial RCT, with a three arm design in which hyaluronic acid + lidocaine 1% (A) were compared to triamcinolone acetonide + lidocaine 1% (B) and placebo sodium chloride (NaCl) + lidocaine 1% (C). In this trial we could prove a significant improvement in pain for triamcinolone acetonide after three, six and twelve weeks. Compared to placebo, injections containing hyaluronic acid did not show a significant improvement in pain .In this study we investigated the effect of subacromial injections in the first days after administration. We also investigated the effect of repetition of subacromial injections on the perceived amount of pain in order to study an accumulative effect of repeated injection.This study was approved by the Medical Ethics Review Committee (MERC) of the Maastricht University Medical Center (MUMC) and was performed at the outpatient clinic of our orthopedic surgery department. Written informed consent was obtained from participants. A total of 159 patients were included in the study, including 75 men and 84 women with a mean age of 53 years (range 20 to 87). A large majority of patients could be included after direct referral by general practitioners. These patients did not receive prior injection treatment by their general practitioners for their current episode of shoulder pain.Patients were randomized into three treatment groups and were blinded for their respective treatment. Eligible patients were over 18 years of age and had pain in the shoulder, either at rest or on movement. The diagnosis of impingement was made clinically without the routine use of ultrasound or MRI. All presented with a painful arc, with or without abnormal scapulohumeral movement.Exclusion criteria included: pain for less than six weeks; injection with corticosteroids in the preceding three months; flexion of <100° in the frontal plane; external rotation limited by >50% compared with the opposite side; allergy to lidocaine 1%, steroids or hyaluronic acid; pregnancy or suspected pregnancy; dementia; prior infection of the shoulder joints; tumour; osteoporosis; rheumatoid arthritis according to the American College of Rheumatology (ACR) criteria ; referreTreatment consisted of subacromial injection with either: a mixture of 8 ml lidocaine 1% and 2 ml hyaluronic acid (Ostenil)  (group A); a mixture of 8 ml lidocaine 1% with 2 ml triamcinolone acetonide 10 mg/ml (group B); or a mixture of 8 ml lidocaine 1% with 2 ml NaCl 0.9% . Injections were repeated, if necessary, after three and six weeks. In case of complete resolution of pain, no further injections were given .versus >40 years). After selection and baseline assessment, consecutive numbered opaque envelopes of the appropriate stratum were opened by one of several independent trial nurses.Patients were randomized blindly into three treatment groups. An independent statistician (FK) generated a random numbers list which, by permutation of random blocks, block size 9, was balanced for treatments within strata. Strata were based on age . Both physician and patients were blinded to the contents of the syringe. In order to achieve an effective blinded injection a 19 gauge 1.5 inch needle and a 10 ml syringe were used to prevent the physician identifying the difference in viscosity of the administered solutions. The syringes were filled by an independent trial nurse and masked with black adhesive tape. The nurse was thus responsible for the blinding procedure. Inclusion, follow-up assessments and data analysis were blinded for allocated treatment .Injections were administered via a dorsolateral approach through the interval just beneath the dorsal acromial edge, with the patient sitting up . The injThe primary outcome measure was pain as measured on a horizontal 10 cm visual analogue scale (VAS)  . MeasureWe investigated the effect of injections of A, B and C on a daily basis using a pain diary during the 21th days after injection. In this study we focus on the effects of repeated triamcinolone acetonide injections versus placebo and hyaluronic acid, illustrating the potential benefit of a series of injections.The pain diary was used to record the perceived amount of pain. With the pain diary we are able to show the immediate daily response the first days after injection. Pain diaries have been shown to be valid and reliable in the measurement of pain in patients with chronic pain and cancer. It is reported that patients tend to overestimate their remembered pain and psychosocial and pain related factors tend to bias the remembered pain. The daily self-recording of pain by a pain diary showed to reduce the amount of bias .Secondary outcome measures consisted of the type and amount of escape medication taken and the occurrence of adverse effects.During the first visit patients were thoroughly instructed how to fill out the paper and pencil pain diary. Patients were told to record the maximum experienced pain for each day.In the pain dairies the days were separated. For each day a VAS score could be recorded on a 10 cm line.Although patients were instructed that only escape medication consisting of acetaminophen (paracetamol) was allowed, they were asked to record the type and amount of escape medication taken for each day.A final question for each day consisted of the occurrence of adverse effects. The perceived adverse events were recorded on a text free basis.Patients were instructed to complete the diary on a daily basis, they were suggested to fill out the diary at the same moment each day to improve compliance.For this study we obtained data of patients enrolled in the RCT. The number of participants was based on the power calculation used for the RCT in which we had calculated a total number of 159 participants, 53, per group, allowing for a dropout rate of 10%. The power calculation of the RCT was based on the decrease in pain on a VAS score .First, data were tested for normality. Second, a missing value analysis was performed. In case of loss to follow-up or withdrawal resulting in missing data, these values were handled by the method of linear trend at point imputation. Analysis of variance was used to establish effects of both interventions. The influence of prognostic variables and baseline differences for outcome measures was assessed in a multivariate linear regression model with imputation of most important baseline variables. Influential variables were used to correct the outcome of the analysis of variance. Statistical significance was set at a p-value <0.05 .All of the 159 included patients received the first allocated injection. The second and third allocated injections were received by 150 patients. Nine patients (6%) did not receive the second and third injection, 3 in each of the groups. In the hyaluronic acid group reasons for not receiving the allocated injections were: withdrawn because of malignancy (n = 1), lost to follow up (n = 1) and not wishing to continue (n = 1). In the triamcinolone acetonide group reasons for not receiving the allocated treatment were: withdrawn because of too much pain (n = 1), lost to follow up (n = 1) and complete relieve of pain after 2 injections (n = 1). In the NaCl injection group reasons for not receiving the allocated treatment consisted of too much pain (n = 2) and lost to follow up (n = 1).  Figure 1After each injection the result of the Neer test was recorded . In the The analysis at baseline did not show any significant differences among the groups. At baseline the VAS score of the triamcinolone acetonide group was 5.8 (95% CI 5.1-6.5), of the hyaluronic acid group 6.1(95% CI 5.4-6.8) and of the NaCl group was 5.9 (95% CI 5.1-6.5).3% n = 14) of the diaries was not returned, due to withdrawal from the study or lost diaries. In the hyaluronic acid group four diaries from the, first period, and two diaries of the second and third period were not returned. In the triamcinolone acetonide group two diaries in the first period, and one diary in the second and third period were not returned. For the NaCl group in both the first and second period one diary was not returned. In the third period al diaries were returned. (Table 4 of the Concerning the secondary outcome measures we report significant differences in the number of persons in need of escape medication. The hyaluronic acid group and the NaCl group needed significantly more escape medication because of pain throughout the study Tables Adverse effects described in the free text of the pain diaries consisted of: flushes, headache, nausea, redness at injection site and tingling sensations. 24 patients reported adverse effect, The most reported adverse effect was occurrence of headache. This occurred in 8 patients in the hyaluronic acid group, in 5 patients in the triamcinolone acetonide group and in 4 patients in the NaCl group Table We could show a significant reduction in pain after a triamcinolone acetonide injection as we described in the results of the RCT . In the In literature most studies describe a repetition of corticosteroid injections in the treatment of shoulder disorders , 21.A number of studies focus on the negative side effects of corticosteroid injections. In these studies merely the effect on the cuff tissue is described with increased damage of this tissue as summarized in the systematic review of Dean . The groThere are some limitations concerning our study, the selection of patients before entering the study was performed without use of MRI or Ultrasound, this might give some bias in the selection. In general practice however most patients will be treated based on a clinical diagnosis. The results of this study therefore can be used for extrapolation to general practice.The injections where placed without use of ultrasound guidance. A recent study however showed that there is little evidence for the need of ultrasound guided needle placement .As far as we know there are no studies which show the short term accumulative effect of corticosteroids in pain reduction. One of the strengths of our study is that we were able to show a booster effect of a repeated triamcinolone acetonide injection after the second injection.In the previously published results of the RCT we could show a significant reduction in pain on a VAS score after triamcinolone acetonide injection at three, six and twelve weeks. In the current study we were able to show the results at nine weeks after the start of the trial. Given the limited effect of reduction in pain after the third injection it is questionable whether it is necessary to administer more than two injections in case of subacromial impingement .An increase in pain after corticosteroid injection is a common adverse effect . AlthougIn the first week after injection of triamcinolone acetonide we could show a fast reduction in pain. After the second injection we could show a limited booster effect of repeated triamcinolone acetonide injection. We were able to graphically show this booster effect of fast reduction in pain after the triamcinolone acetonide injection by displaying the patient perceived pain on a VAS score in the days after injection. Given the limited effect in pain reduction after the third triamcinolone acetonide injection there might be evidence to reduce the total number of repeated triamcinolone acetonide injections to two injections.Compared to Hyaluronic acid and NaCl injections, triamcinolone acetonide injections showed a fast and effective reduction in pain on a VAS score already after a limited number of injections.