Background: In the last few years, transcranial direct current stimulation (tDCS) has emerged as an appealing therapeutic option to improve brain functions. Promising data support the role of prefrontal tDCS in augmenting cognitive performance and ameliorating several neuropsychiatric symptoms, namely pain, fatigue, mood disturbances, and attentional impairment. Such symptoms are commonly encountered in patients with multiple sclerosis (MS).Objective: The main objective of the current work was to evaluate the tDCS effects over the left dorsolateral prefrontal cortex (DLPFC) on pain in MS patients.Our secondary outcomes were to study its influence on attention, fatigue, and mood.Materials and Methods: Sixteen MS patients with chronic neuropathic pain were enrolled in a randomized, sham-controlled, and cross-over study.Patients randomly received two anodal tDCS blocks (active or sham), each consisting of three consecutive daily tDCS sessions, and held apart by 3 weeks. Evaluations took place before and after each block. To evaluate pain, we used the Brief Pain Inventory (BPI) and the Visual Analog Scale (VAS). Attention was assessed using neurophysiological parameters and the Attention Network Test (ANT). Changes in mood and fatigue were measured using various scales.Results: Compared to sham, active tDCS yielded significant analgesic effects according to VAS and BPI global scales.There were no effects of any block on mood, fatigue, or attention.Conclusion: Based on our results, anodal tDCS over the left DLPFC appears to act in a selective manner and would ameliorate specific symptoms, particularly neuropathic pain. Analgesia might have occurred through the modulation of the emotional pain network. Attention, mood, and fatigue were not improved in this work. This could be partly attributed to the short protocol duration, the small sample size, and the heterogeneity of our MS cohort. Future large-scale studies can benefit from comparing the tDCS effects over different cortical sites, changing the stimulation montage, prolonging the duration of protocol, and coupling tDCS with neuroimaging techniques for a better understanding of its possible mechanism of action. Multiple sclerosis (MS) is a chronic progressive inflammatory disease of the central nervous system, and represents the major cause of non-traumatic disability in young adults  in the circuits of pain  is currently being investigated for the management of neuropsychiatric symptoms when pharmacological interventions fail. Among those techniques, transcranial direct current stimulation (tDCS) has gained a particular interest in recent years, and appears to be a promising tool for the treatment of several neurological disorders. It acts by changing the cortical excitability . The trial is registered at the Deutsches Register Klinischer Studien (drks-neu.uniklinik-freiburg.de) and has the following registration number: DRKS00005296. All participants were well instructed about the protocol and voluntarily gave their written informed consent prior to inclusion.0−100), obtained as the average of daily scores over a representative week.Patients were enrolled by M.A., M.S., D.D., and A.C. from the Neurology department of Henri Mondor Hospital, Créteil, France, between November 2012 and November 2014 according to the following criteria: (i) a definite MS diagnosis according to the 2010 revised McDonald criteria  MS relapses within the last 2 months; (ii) changes in pharmacological and physical therapies during the last month; (iii) the presence of comorbid neurodegenerative or psychiatric disorders; (iv) history of substance abuse; (v) absence of measurable pain related evoked potentials (PREPs) at the right hand; (vi) severe deficit in the visual acuity or fields as documented by an ophthalmic exam; and (vii) severe right upper limb impairment as per the Medical Research Council scale for muscle power (MRC) , soaked in a saline solution to minimize the risk of skin irritation  which is below the threshold for tissue damage  delivered the direct current over the scalp through sponge electrodes  was aware of the stimulation mode . The evaluators (U.P and M.A.C) and the patients were blind to it.0−100 and the short version of the Brief Pain Inventory (BPI). The latter is a validated and reliable tool to measure pain intensity and its interference with patient's life . The PPT was determined by the method of limits, which consists of raising the stimulus intensity from zero to the point where the stimulus is perceived as painful sensation at intensity of 60–70 on VASStimulation was carried out using a concentric electrode designed to excite the superficial skin layers, hence the nociceptive axons , fixed to the scalp surface using a special paste . The electrodes were positioned as the following: the recording one at Cz , the reference one at the left earlobe, and the ground one with a Velcro strap around the right forearm . In addition, electro-oculogram was obtained via pre-gelled adhesive surface electrodes  placed at the right infraorbital lateral margin.After determining the PPT, two sets of twenty stimuli were performed at irregular intervals, at VASThe recorded signal was bandpass filtered at 0.5–30 Hz and stored for analysis using a Keypoint machine . The final step consisted of averaging the signals offline, and excluding the contaminated recordings . We then analyzed the collected N2-P2 responses and measured their baseline-to-peak amplitudes, peak-to-peak amplitudes, and latencies.The frontal midline theta (FmΘ) is an oscillatory activity in the theta band (4–7 Hz) that appears in the medial frontal region at any time during the performance of a cognitive task, reaching 6–7 Hz in frequency and 30–60 mV in amplitude  in a given raw EEG signals we determined the frequencies that dominate each signal.First, the signals were band-pass filtered in the frequency bands [0.5–3.5 Hz], [4–7 Hz], [8–12 Hz], and [13–30 Hz] corresponding to the rhythms delta, theta, alpha, and beta respectively. To take into account the difference in the amplitudes of these rhythms, we determined the gradient of their amplitudes, looked for their envelopes, and calculated the modulus of the Hilbert transform of the gradients in question Marple, . At eachAfter the inclusion session, patients were randomized to receive either sham or active tDCS block Figure . The ranKeeping in mind the fluctuating nature of neuropathic pain, and the effects of circadian rhythm on attentional capacities, the patients underwent the experimental protocol at the same time of the day , they were asked to fill questionnaires for pain (BPI), fatigue (MFIS), anxiety and depression (HADS). This was followed by PREPs recording, the performance of ANT test, and finally the tDCS session. The latter was repeated at the second (D2) and third (D3) day of each block. At D3, the above-mentioned evaluations were repeated following the stimulation session, and the patients' degree of satisfaction regarding the protocol was assessed using the Comfort Rating Questionnaire (CRQ) and the Global Clinical Impression (GCI). At the end of each block, the patients were asked to guess the mode of stimulation (active/sham). A schematic diagram is shown in Figure The patients daily recorded the average of their pain intensity 1 week before and 1 week after each block using VASd third D day of et-tests, and those with a p < 0.05 were considered significant. This included PREPs (amplitudes and latencies), ANT parameters (MA and RT), frontal theta activity percentages, and self-rating questionnaires scores for pain , fatigue (MFIS), anxiety and depression (HADS).For the ANT parameters, we excluded from the analysis the reaction times of trials with either error or with a reaction time value above or below the mean ± 2 standard deviations (SD). Statistical analyses were performed using the StatView and InStat software. Our Data followed normal distributions according to the method of Kolmogorov and Smirnov. Data collected before and after each block were analyzed with paired Twenty MS patients were enrolled, and four were excluded . Sixteen patients  completed the study , antidepressants , opioids  and immunomodulating agents (13 patients). Pharmacological treatment was continued and kept stable throughout the experimental protocol.After both active and sham stimulation, six patients reported insomnia. Nausea was reported by five patients after active stimulation and by four patients after sham stimulation. Severe headache occurred in three patients after active stimulation and in one patient after sham stimulation. Phosphenes were reported by one patient after sham stimulation.p = 0.96) and after stimulation (p = 0.43). No significant differences were observed between both stimulation conditions on the overall discomfort (p = 0.79) or the mean GCI . Details are provided in Table No significant difference was found between both conditions regarding the CRQ sum scores during (0−100 pain ratings 7 days before and 7 days after stimulation showed significant decrease after active tDCS (p = 0.024), but no change after sham tDCS (p = 0.66). Analogously, the mean VAS0−100 pain ratings for days 1–3 before and after stimulation showed significant decrease after active tDCS (p = 0.021), and no improvement after sham tDCS (p = 0.56).The mean VASp = 0.02), and its interference subscale (p = 0.01), but had no significant effects on the severity subscale. Sham did not have any significant effects on BPI scores or its subscales. Pain scores are found in Table Active stimulation resulted in a significant improvement of BPI global score p = 0.0, and itsThere were no significant changes in any of the ANT parameters after both sham and active stimulation Table .The baseline mean global MFIS score, HADS anxiety and depression subscales were 52.6 ± 12.2, 9.2 ± 4.0, and 6.6 ± 3.2, respectively.No significant differences were observed following both stimulation conditions for the MFIS total scores, HADS total scores and subscales. The neuropsychological scores are detailed in Table PREPs results did not significantly differ between active and sham stimulation Table .p = 0.09), and theta Fz showed significant increase after sham stimulation (p = 0.04). After active stimulation, theta Fpz and Fz increased by trend , ANT parameters, fatigue and mood scales. Lastly, a trendwise or a significant increase in the frontal theta activity was observed following active or sham stimulation, respectively.This study aimed to explore the impact of prefrontal tDCS on pain in 16 MS patients. Active anodal but not sham tDCS showed significant analgesic effects on VASThe most prominent effect of tDCS treatment was analgesia. Such findings are of high interest and in line with previous studies. In fact, the DLPFC is known to have a crucial role in modulating pain , prolonging the duration of the stimulation period, adding a within-day control for attention, and adopting a different reference site, before drawing any conclusion.As for mood changes, although there are evidence regarding the antidepressant effects of anodal tDCS over the DLPFC (Kalu et al., Concerning fatigue, we found no effects of tDCS on the MFIS scores. A lack of improvement in fatigue following tDCS has already been reported by two studies (Ferrucci et al., PREPs amplitudes were not changed following both active and sham tDCS. Although PREPs can correlate with the subjective pain sensation, it is commonly accepted that PREPs amplitude reflects the integrity of the spino-thalamo-cortical tract (Casey et al., As for the frontal midline theta activity, their increase following both stimulation blocks can be explained by different approaches. In fact, anxiety improvement has previously been correlated with the appearance of such waves following anxiolytic treatment (Mizuki et al., It is important to note that, in our patients' cohort, the observed tDCS effects could have been influenced by antiepileptic treatments. The latter are known to inhibit long-term-potentiation induced neuroplasticity changes by blockade of voltage-gated ion channels (Nitsche et al., MA, MS, DD, and AC: enrolled patients from the neurology department of Henri Mondor Hospital. SA, UP, and MC: performed the stimulation sessions and collected the data. SA and JL: designed the study, developed the methodology, interpreted the data and wrote the final draft. MC and UP: wrote the first draft. TA and AB: analyzed the EEG data.AC gave expert testimony for CSL Behring, Novartis, received grants from Biogen, Novartis, CSL Behring, GE Neuro, Octapharma, and gave lectures for Genzyme. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Despite high success rate of DREZ lesioning in the treatment of intractable central pain, there is still a significant incidence of patients without satisfactory post-operative effect. The aim of the study was to evaluate the long-term effect of DREZ lesioning using both a subjective assessment using a visual analog scale (VAS) to quantify residual pain and an assessment using the screening tool .DREZ lesioning was performed in 52 patients from a total 441 cases with brachial plexus injury (11.8%) during a 17-year period (1995–2011). The effect of surgery was retrospectively assessed in 48 patients.A decrease in pre-operative pain by more than 75% (Group I) was achieved in 70.8% of patients and another 20.8% reported significant improvement (Group II). The surgery was unsucessful in 8.4% (Group III). We found a significant correlation between ‘improvement’ groups from both methods of assessments. Patients from Group I usually complained of residual nociceptive pain according to PD-Q, patients from Group II typically had pain of unclear origin, and all cases those in Group III suffered from neuropathic pain, Cramer’s V = .66, P < .001. Overall, 66.7% of patients had resolved neuropathic pain, 20.8% patients had more serious complaints and may also suffer from residual neuropathic pain, while 12.5% had unresolved neuropathic pain.DREZ lesioning is a safe and effective method with success rates of about 90%. PD-Q scores correspond to subjective satisfaction with the surgery and it seems to be a suitable screening tool for finding patients with residual neuropathic pain after surgery. Pain is an early symptom in up to 70% of patients with brachial plexus injury. In up to 20% of cases severe intractable pain develops. Persistent pain with sporadic acral irritations described by patients as cutting or burning, is typical ,2. In 90To our knowledge, no study has evaluated residual neuropathic pain or success of DREZ-T using a screening tool. The painDETECT Questionnaire (PD-Q) was developed in Germany for use in individuals with back pain and incorporates an easy to use patient-based (self-report) questionnaire that does not require a clinical examination .The aim of this study was to evaluate the long-term effect of DREZ-T in patients treated for severe neuropathic pain that developed after brachial plexus injury. The evaluation used both a subjective assessment using a visual analog scale (VAS) to quantify residual pain and an assessment using the PD-Q score . AdditioA total of 52 DREZ thermocoagulations have been performed, by the senior author, during the period 1995 – 2011 . Surgical procedures were completed on 48 men and four women with an average age of 40 years . Twenty-nine cases were localized on the right and 23 on the left side. Patient data are summarized in Table The study was approved by the hospital institutional review board and informed consent to participate in the study and for the publication of individual clinical details was obtained from each patient.Patients were indicated for DREZ-T after development of severe, unbearable pain in the affected extremity after all types of analgesia  had been tried and found to be inadequate. The vast majority of procedures were performed before a planned reconstruction of the brachial plexus. All patients underwent preoperative EMG examination using needle concentric electrodes and nerve conduction studies. CT myelography showed avulsion of minimally two cervical roots in all patients.The procedures were performed in the semi-sitting position with the head fixed in three-point fixation after shaving the occipital area. An incision was made vertically from external occipital protuberance to the vertebra prominens. Multilevel hemilaminectomies (2–4) were performed to expose the spinal cord at the level of the nerve root avulsion. Laminectomy and durotomy were extended until finding the nearest outgoing posterior root. The lesions were made after DREZ localization (see below), using a radiofrequency electrode with a tip depth 2 mm under the spinal cord surface. Lesioning time was 15 s, lesioning temperature was 75°C; lesioning device was a Radionics RFG-3C Plus .The strip electrode with two active members  was slipped under the dura at the rostral end of exposed spinal cord. Responses were amplified at a gain setting of 100 with the high frequency filter set at 5 kHz and the low frequency filter set at 20 Hz. Responses were not averaged . The stimulating electrode was a bipolar stimulating electrode with constant distance between tips of 1 mm. A 200-μsec square-wave impulse and a stimulation rate of 3 stimuli per second were used.Initially the stimulating electrode was placed over the dorsal column. The distance between stimulating and recording electrodes varied from 3 to 8 cm. The intensity of the stimulus was gradually increased until an evoked potential with amplitude of approximately 30 – 50 uV was elicited. The stimulus intensity was not changed during the rest of procedure and ranged from 0.1 to 0.9 mA. Using an operating microscope, the neurosurgeon gradually stimulated dorsolateral surface of spinal cord at a constant distance from the registration electrode, in approximately 2 mm steps. Sites where the stimulation electrode failed to evoke a response were considered DREZ and a thermocoagulation lesion was made at that site. The stimulating technique was repeated along the long axis of the spinal cord at 1 cm intervals. Our operative technique was previously published .All patients were hospitalized for one week. Patients were examined clinically every half year. Minimum time of follow-up was two years. The last evaluation was a clinical examination at our outpatient clinic in the more recent cases or via mail in patients who underwent surgery more than five years ago. At first, the residual pain was assessed using VAS with the present-day score counted as a percentage decrease from the original level. Based on these scores, patients were divided into three groups according to intensity of residual pain Table . Next thhttp://www.r-project.org). Significance was assumed at p <0.05.The results were analyzed using ANOVA with post-hoc analysis using the Fisher LSD test (for continuous data) and Cramer’s V and Yates Chi-square test . Analyses were done using Statistica 10.0 software  and R . Fifty-one patients had procedures before or just after reconstruction of the brachial plexus; one man was successfully treated 28 years after the original accident. Of the 441 patients undergoing a brachial plexus reconstruction, the thermal lesion group represented 11.8%. Of 52 patients treated with thermal lesions, we were able to obtain data regarding the subjective assessment of their condition in 48 cases. Two men died of unrelated causes and another two patients could not be contacted for the final follow-up examination.A decrease in pre-operative pain intensity of more than 75% was considered a definite success. Based on our follow-up, this goal was achieved in 70.8% of patients. Another 20.8% reported significant improvement, but with some pain persistence, usually in the form of dull pain or paresthesias of the affected upper limb. Overall satisfaction with the surgery was achieved in 91.6% of patients. The surgery was considered to be unsuccessful in the remaining four cases (8.4%). In two cases, after improvement in the early post-operative period, progressive worsening to the original level began at one and three months post-surgery. The two other cases reported persistence of very severe dull pain. In one case the patient decided to amputate the affected limb; however, this also failed to resolve the issue (No. 30).The PD-Q score was in agreement with subjective assessments of residual pain: the average pain score in Group I (7.85) was statistically significantly lower than in Group II . Both are significantly lower than in Group III . We found a statistically significant correlation between adequate-treatment groups  . It was observed that 32/48 (66.7%) patients lost neuropathic pain, 10/48 (20.8%) patients had more serious complaints and may ultimately suffer from residual neuropathic pain while 6/48 (12.5%) had neuropathic pain. Details are summarized in Table Post-operative complications occurred in 8 (15.4%) patients. In five cases, sensory deficits  occurred. Motor leg weakness occurred in two patients and one case had a combined disability. Excluding the patient with hemihypoesthesia, in which there was a partial restoration of body sensitivity, all other patient complaints resolved and returned to pre-operative conditions.The success and safety of DREZ-T in the treatment of intractable central pain caused by cervical root(s) avulsion have been confirmed repeatedly -10,13-15An operative painkilling surgery is generally required in 10 to 15% of patients with spinal cord root avulsion ,17. ChenWe divided patients into three groups Table  accordinIt has been stated that there is no correlation between the number of roots avulsed or the extent of the DREZ-T procedure performed and the degree of pain reduction . The besThe PD-Q was validated in a group of 392 individuals with nociceptive and neuropathic pain. Of its nine items, seven relate to sensory responses and two relate to temporal and spatial characteristics of the pain pattern. A total score ≤12 indicates that a neuropathic pain component is unlikely, whereas a score of ≥19 indicates that a neuropathic component is likely. Between these values the result are uncertain and a neuropathic pain component could be present. It has more than 80% sensitivity, specificity and positive predictive accuracy in the diagnosis of a neuropathic component in patients with low back pain . It can If we compare the success rate using a VAS decrease and the PD-Q scale, the results are similar (p <0.001): 70.8% (Group I): 66.7% (nociceptive pain), 20.8% (Group II): 20.8% (unclear pain) and 8.4% (Group III): 12.5% (neuropathic pain). The small differences probably result from (1) individual subjective assessment of pain intensity or (2) even if pre-operative pain intensity decreased dramatically, it is still possible that the patient has residual neuropathic pain. Our results suggest two clear conclusions about residual pain in our patients: (1) patients who are very satisfied with the effect of surgery (Group I) most often suffered from (obvious) nociceptive pain (85.3%) and (2) patients, in whom the surgery failed, had suffered from (obvious) neuropathic pain . Patients in Group II, who were partially satisfied with the effectiveness of the surgery, might very well, suffer from a combination of nociceptive and neuropathic pain. The presence of nociceptive pain after brachial plexus injury seems to be unexpected. However, it may originate in the areas of preserved nerve supply in incomplete injuries or develop later in the areas reinnervated by neurotization. We can therefore conclude that it would be useful to evaluate patients who were not fully satisfied with the effectiveness of the DREZ-T surgery, using a screening tool like the PD-Q, which could reveal a potential neuropathic component of their residual pain. In such cases, a more effective conservative treatment would be indicated.The risk of this procedure includes potentially serious neurological complications. The close proximity of corticospinal tract laterally and dorsal column medial lemniscal tract dorso-medially creates a risk motor failure of the ipsilateral lower extremity or sensitivity failure from the point of damage with lower limb ataxia, respectively. Anatomical and functional localization of DREZ is therefore essential for overall success. With careful monitoring, finding of vertical zero line is not usually difficult even though it is known that the distance from the midline to the DREZ can be quite variable . ProblemRecent information has clouded the issue of deafferentation pain and made it a little less simple than previously thought. Deafferentation pain probably does not occur in children  . Aly et We conclude that approximately 90% of our patients were satisfied with the effectiveness of DREZ thermocoagulation for intractable deafferentation pain after a brachial plexus injury.


The relationship between scoliosis magnitude, HRQL and Self Perception of Trunk Deformity is not clear. To better understand this, a prospective data collection including age, main thoracic and lumbar or thoracolumbar Cob angle, Trunk Asymmetry Perception Scale TAPS (1), SRS-22  and current treatment was started involving all patients with idiopathic scoliosis attending a rehabilitation clinic, 10 years of age or older at the time of consultation. The data have been retrospectively analyzed and are presented in several studies. This is the study II.The aim of this study was to determine whether patients showed differences in their HRQL depending on the type of treatment.N 240; mean age 19.3 y + 10.3 (10-62), mean Cobb thoracic 33.7º + 13.8, lumbar or thoracolumbar 29.7 + 12.7. At the time of consultation patients were or had been untreated or treated . Statistics: SPSS.Untreated patients: N 76; Mean Cobb Thoracic 19º; Lumbar/TL 17.5º; Means SRS-22 Pain 21.07; SRS-22 MH 19.64; SRS-22 SI 18.66; SRS-22 F 22.38; SRS-22 Sub Total 81.83. Treated with Exercises exclusively: N 36; Thoracic 24.6º; Lumbar/TL 22.4º; Pain 21.19; MH 20.11; SI 18.94; F 21.75; Sub Total 82.03. Treated with Chêneau+SPE: N 56; Thoracic 29º; Lumbar/TL 22.2º; Pain 22.75; MH 20.20; SI 19.55; F 22.71; Sub Total 85.25. Treated with other braces: N 69; Thoracic 34º; Lumbar/TL 24º; Pain 22.07; MH 20.06; SI 18.25; F 22.65; Sub Total 83.03.No significant differences between the untreated group, exercises and other braces. Chêneau+SPE showed better scores in Pain and Function, with bigger curves, in comparison with untreated and treated only with exercises and in SI, with lower curves, in comparison with those treated with other braces.This type of study does not allow to drawn final conclusions but it shows that HRQL seems to be similar in untreated (with milder curves) and treated patients (with bigger curves), all attending a rehabilitation clinic for medical advice or for control, suggesting some positive treatment impact.


Patients with tension-type headache (TTH) and/or migraine are often referred to physical therapy. Only few studies have evaluated the efficacy of individual-based exercise program.To evaluate the effect of individual-based exercise on functional health and well-being, headache frequency and pain intensity in patients suffering from TTH and/or migraine.During an 18 months period 282 consecutive patients entered an open label uncontrolled study in a multidisciplinary headache centre. Diagnoses were according to ICHD-3 beta. Functional health and well-being were measured by using Headache Impact TestTM (HIT-6), scores ranged from 36 (no impact) to 78 (severe impact). Pain intensity was recorded on an 11-point numeric rating scale(NRS-11), 0 = no pain; 10 = worst pain imaginable.So far, 40 women and 14 men, mean age 39.4, completed the study. 28 were diagnosed with TTH, 4 with migraine and 22 with both TTH and migraine.In TTH-patients HIT-6 decreased from 59.6 to 54.4(p<0.01); frequency decreased from 24.9 to 18.0 days/month(p<0.01); pain intensity decreased from 5.8 to 3.9 NRS-11(p<0.01).In patients with combined TTH and Migraine HIT- 6 decreased from 61.3 to 58.8(p=0.06); the TTH-frequency decreased from 20.6 to12.6 days/month(p<0.01), and their migraine frequency from 4.0 to 2.3 days/moth(p=0.03); whereas pain intensity was uneffected .Individual-based exercise has shown a positive effect on functional health and well-being, headache frequency and pain intensity in severely affected patients especially in TTH and less for combined Migraine and TTH. Randomised controlled studies are needed to confirm these findings.No conflict of interest.


Objectives: Patients with idiopathic chronic scrotal pain are challenging to both the general practioner and urologist. In this study, we tried to recognize mild epididymitis as an underrecogniczed cause of idiopathic chronic scrotal pain.Methods: We described a consecutive series of 44 patients with idiopathic chronic scrotal pain characterized by mild scrotal pain, mild to moderate tenderness of epididymis without abnormal swelling of epididymis. We obtained a detailed history and physical examination along with routine urinalysis and Doppler ultrasound to identify the characteristics of this new clinical entity.Results: A consecutive series of 44 patients who were primarily diagnosed as "idiopathic chronic scrotal pain" came to our hospital. All had the sign of mild to moderate tenderness on the affected epididymis without epididymis enlargement. Doppler ultrasound showed the affected epididymis with normal size and no abnormal change. We treated them with antibiotics orally along with cessation of strenuous activity and all fully recovered from scrotal pain.Conclusion: In this study, we recognized mild epididymitis as an underrecogniczed cause of idiopathic chronic scrotal pain. It was characterized by mild scrotal pain, mild to moderate tenderness of epididymis without abnormal enlargement of epididymis.  Pain may be bothersome and without explanation, recurrent or persistent, and it may lead a patient to fear that he has a serious disease. In many cases scrotal pain is idiopathic. These patients are challenging to both the general practioner and urologist, and a clear understanding of the etiology and course of this common condition is needed when treating them.2,3 Desai et al2 classified epididymitis into 3 groups as mild, moderate and severe according to the degree of inflammation.Epididymitis by definition is inflammation of the epididymis. This term of "mild epididymitis" is already fully known in the literature and reserved for specific forms of epididymitis.In this study, we tried to recognize mild epididymitis as an underrecogniczed cause of idiopathic chronic scrotal pain. This series of patients characterized by mild scrotal pain, mild to moderate tenderness of epididymis without abnormal enlargement of epididymis. For the reason of under-diagnosis and high incidence of mild epididymitis, we report a consecutive series of 44 cases of mild epididymitis.1,4,5 were excluded. Patients with post-vasectomy, previous testicular trauma or surgery , tumour, post-infection, post-torsion were excluded. We obtained a detailed history and physical examination along with routine urinalysis and Doppler ultrasound to identify the characteristics of this new clinical entity.We describe a consecutive series of 44 patients with idiopathic chronic scrotal pain characterized by mild scrotal pain, mild to moderate tenderness of epididymis without abnormal swelling of epididymis. Patients with potential causes of chronic scrotal painFrom October 2011 to May 2012, we included a consecutive series of 44 patients who complained of mild scrotal pain over 6 weeks  with milAs shown in We treated them with antibiotics orally along with cessation of strenuous activity. Whether the used antibiotics were effective depended on the relief of scrotal pain or tenderness of epididymis. If the Cephalosporins or Quinolones orally 1 week didn't work, we changed to Doxycycline and Azythromycin to continue the treatment. As shown in 6 In published reports on this subject, the term chronic refers to periods varying from 1 week7 to 6 months.8 In this study, we defined chronic as lasting for at least 6 weeks.Reports of chronic scrotal pain are obscured by differences in the selection of patients and in the definition of the condition.4 The pain is often severe enough to affect the daily activities of the patient, causing them to seek medical help.Chronic scrotal pain poses a special challenge for the urologist. It is difficult to treat, as the cause is often unknown, and might require a multidisciplinary approach. In many patients, the clinical examination is often normal and investigations such as scrotal ultrasonography and microbiological urine analysis can be unremarkable.1,4,5 Pain might be caused primarily by pathology in the scrotum or groin, or be referred from another area (‘referred pain’). Local causes can include chronic infection of the testis or epididymis, testicular tumour, indirect inguinal hernia, hydrocele, spermatocele or varicocele. Referred pain might originate from the ureter (ureteric stone), prostate (chronic prostatitis) or lumbar spine (degenerative lesions). However, in up to 25% of cases no identifiable cause for chronic scrotal pain is found, despite extensive investigation.9There are many possible causes of chronic scrotal pain.2,3 Desai et al2 classified epididymitis into 3 groups as mild, moderate and severe according to the degree of inflammation and the clinical criteria of mild epididymitis is "thickened, tender epididymis testis separately palpable and non-tender". In this study, we found patients with mild epididymitis had no fever, no swelling of epididymis and just had mild scrotal pain, mild to moderate tenderness of epididymis. This and Desai 's study2 are basically the same.Epididymitis by definition is inflammation of the epididymis. This term of "mild epididymitis" is already fully known in the literature and reserved for specific forms of epididymitis.10 Chronic epididymitis refers to inflammation and pain in the epididymis persisting for over 6 weeks.10 As shown in Acute epididymitis represents sudden occurrence of pain and swelling of the epididymis associated with acute inflammation of the epididymis.A consecutive series of 44 patients were enrolled in our study. They didn't seek medical treatment immediately (the median duration of onset to first visit was 5 weeks). Most (38/44) were unilateral involvement. We tried to treat them with antibiotics orally along with cessation of Strenuous activity. A 1- to 8-week trial of antibiotics should potentially be effective against possible bacterial pathogens. As shown in 6. When no diagnosis can be made on the basis of a thorough physical examination, a scrotal ultrasound is often performed.6 Although several studies have demonstrated the accuracy of diagnostic ultrasound of the scrotum and its contents, in patients with chronic scrotal pain and a normal physical examination, there is no scientific basis to perform this test.6 In this study, we have shown that all the patients with mild epididymitis had normal epididymis results of ultrasound. Its characteristic sign is mild to moderate tenderness of epididymis without abnormal enlargement of epididymis. After checking carefully, we can easily determine the diagnosis. Doctors should learn again to put their trust in their abilities to perform a physical examination of the scrotum.6 Although there is little harm, other than economic reasons and its burden on radiologic services, to use a simple and fast modality such as ultrasound, its main indication seems to be to reassure the patient and his doctor that no serious pathologic features are present.6In many patients with chronic scrotal pain, no clinical abnormalities can be found. There is a tendency not to rely any longer on physical examination aloneIn this study, we have recognized mild epididymitis as an underrecogniczed cause of idiopathic chronic scrotal pain. This series of patients was characterized by mild scrotal pain, mild to moderate tenderness of epididymis without abnormal enlargement of epididymis. After the treatment, all the 44 patients recovered from the scrotal pain.


Burn is a tragedy that follows multiple problems in a patient including pain, anxiety and lack of confidence into medical team. This study evaluated the effect of shiatsu massage on pain intensity of burn patients.A total of 120 burn patients from Motahhari Burn Hospital and of both genders were randomly divided into 4 groups of undergoing hand massage, leg massage, both hand and leg massages, and the control group. The effect of shiatsu massage in pain relief of burned patients was evaluated. The visual analog scale (VAS) was used to assess pain in burn patients. p=1). In all massage groups, the difference for pain intensity before and after the intervention was statistically significant. Pain intensity in the control group before and after the intervention was not statistically significant (According to our data, shiatsu method over both hands and legs were effective in pain reduction and can be recommended together with analgesics to decrease the dose. Burn is a tragedy with many problems such as pain12 Tranquilizers that are most often prescribed by physicians may be associated with side effects such as respiratory system suppression and drowsiness.13 One of the methods in reducing pain was shown to be the use of massage.14 as a complementary therapy reducing the need for analgesic drugs and also limit the side effects in burn patients. A common method of pain control in burned patients is use of narcotic analgesics, even the use of narcotic analgesics alone cannot completely relieve the pain in burn patients.15 This study evaluates the effect of shiatsu massage on pain intensity in burn patients.Shiatsu as a complementary massage therapy is the pressure and scrubbing of the energy pathways in the body based on knowledge and application of energy to treat and relieve pain in any part of the underlying diseases.15 In all massage groups, the patients were placed on a bed or chair in a comfortable position and received the massage for 20 minutes. During the massage, the patients closed their eyes and focused on the procedure as reported before.16 The visual analog scale (VAS) was used to assess pain in burn patients as described before.17 In all groups, data collection was done before and after the intervention. Data analysis was performed using SPSS software  and paired t-test. A p value less than 0.05 was statistically considered significant.The study population was consisted of 120 burn patients from Motahhari Burn Hospital and of both genders. They were randomly divided into 4 groups of undergoing hand massage, leg massage, both hand and leg massages, and the control who did not receive any massage. The effect of shiatsu massage in pain relief of burned patients was evaluated as described before.p=1). In all massage groups, the difference for pain intensity before and after the intervention was statistically significant (p=0.001) while the pain intensity before the intervention was higher. Distribution of pain intensity score before massage was higher in control group in comparison to other groups (Pain intensity in the control group before and after the intervention was not statistically significant (r groups . After mr groups . 14,15Our findings showed no significant difference between massage groups and control group regarding pain severity before massage. There was a significant difference between massage groups and control group regarding pain severity after massage. So massage may be an important therapy in management of pain in burned patients and shiatsu can be a model for future researches in complementary medicine in primary care system. Leg and hand massage was more effective in burn pain control in comparison to leg and hand massage only. In reducing pain, other researchers reported the efficacy of massage in pain reduction.So we can suggest a 20 min hand, leg, hand and leg massage intervention in conjunction with analgesics to control the pain in burn patients decreasing the needed dose of analgesics.The authors declare no conflict of interest.


Up to now no therapy study has used the classification system of the Quebec Task Force (QTF) to differentiate between patients with (QTF II°) and without functional disorders (QTF I°). This differentiation seems meaningful, as this difference may be relevant for the correct treatment planning. In this context the effect of the therapy recommendation “act as usual” has been evaluated in a homogeneous patient collective with whiplash injuries QTF I°.470 patients with acute whiplash injuries had been catched in this study and classified according to the QTF. 359 patients (76.4%) with QTF I° injuries could be identified. Out of that 162 patients were enrolled to the study and received the therapy recommendation “act as usual” and the adapted pain treatment with non-steroidal anti-inflammatory drugs (NSAID). After six months the outcome was evaluated by phone.After injury the median pain score assessed by a visual analogue scale (VAS) was 5.4 . After six months 5 of the 162 patients complained intermittent pain symptoms . This is consistent with a chronification rate of 3.1%. After injury, the median pain disability index (PDI) was 3.9 . After six months 3 of the 162 patients stated persisting disability during sporting and physical activities .The therapy recommendation “act as usual” in combination with an adapted pain treatment is sufficient. Usually patients with whiplash injuries QTF I° do not need physical therapy. An escalation of therapy measures should be reserved to patients with complicated healing processes. In the age of increasing private transport, one can observe a steady increase in the incidence of whiplash injuries of the cervical spine . For exaWith this objective, previous studies have compared a wide variety of therapy measures such as mobilisation , machineWhile in 1995, the Quebec Task Force (QTF) could not yet find a reliable indication of the superiority of these measures in the treatment of whiplash injuries of the cervical spine as compared to spontaneous recovery  with the recommendation to take the medication for ten days. The patients were asked to document the period of how long the painkillers were taken.Three days after the whiplash trauma, patients’ pain score and disability score were determined and their range of motion in the cervical spine was assessed. In a detailed consultation session, the patients were explained the quality of injury without any gravity. The patients were given the recommendation to resume their usual activities without changing anything. A certificate of disability of maximal five days was only issued if the patient had occupational activity with a high level of physical exposure. No further therapeutic measures were recommended.The patients were asked, to contact the study doctors if the symptoms last longer than two weeks. After six months the patients were contacted by phone. In patients with persisting symptoms the pain score and disability score were determined as well as their range of motion in the cervical spine was assessed again in a second examination.Patients’ pain score was determined using two semi-quantitative visual analogue scales (VAS), each 10cm in length. Zero value represents no pain and value 10 represents maximal pain intensity. Pain scores below 0.4 can be considered as no pain, between 0.5 to 4.4 as mild pain, 4.5 to 7.4 as moderate pain and 7.5 to 10 as severe pain . PatientPatients’ disability score was determined on the basis of seven semi-quantitative VAS, each 10cm in length . Zero vaData were evaluated descriptively. Results were tested for statistical significance using the Wilcoxon test for paired samples. The percentage rate of persisting pain was determined using the results obtained at six-month follow-up.Out of the 470 patients (283 women and 187 men) between 18 and 68 years (median: 45 years) with acute whiplash injuries 359 patients (76.4%) were classified as QTF I°, 75 patients (16.0%) as QTF II°, 18 patients (3.8%) as QTF III° and 18 patients (3.8%) as QTF IV°. 162 patients with QTF I° whiplash injuries of the cervical spine  and free range of motion could be investigated in this study.After injury the median pain score assessed by VAS was 5.4 . In the further study course no patient used the telephone hotline to complain persisting pain. After six months 5 of the 162 patients interviewed by phone complained intermittent pain symptoms with VAS values < 2 see . This isAfter injury, the median PDI was 3.9 . After six months 3 of the 162 patients interviewed by phone stated persisting disability during sporting and physical activities. The disability score was < 1 in all of the three patients see .The results of this study show that the occurrence of so-called minimal whiplash injuries (QTF I°) with a percentage of 76.4% is relatively high. In this patient collective the initial pain treatment and the therapy recommendation “act as usual” led to a satisfying healing course with a quite low chronification rate of 3.1%.Up to now the therapeutic recommendations for both patient collectives (QTF I° and QTF II°) has been the same As already stated in the introduction section up to now only mixed populations with QTF I° and QTF II° patients has been investigated. This fact influences not only the prognosis but also the necessity of an appropriate therapy plan. As the QTF I° patients only complaint pain symptoms without a functional deficit therapeutic measures, which are aimed to protect or restore structural limitations, are not justified. The mainly therapeutic goals for these patients should be the adequate pain treatment and the quickest possible reestablishment of a complete analgesia.In this study – under strict selection of the appropriate patients – the therapy recommendation “act as usual”, which guarantees a cheap and simple therapy option, has been evaluated. The principle of the therapy recommendation “act as usual” is based on the assumption that the sustained injury is self-limiting. The goal of that is the quickest possible socio-professional reintegration of the patients.Secondary benefits of being sick, the attention given by medical staff, the taking advantage of work incapacity, the speculation of legal proceedings and the mental expectation of further diagnostic or therapeutic measures are discussed as possible reasons for the occurrence of pain chronification . TherefoThe results of this study – investigating isolated patients with QTF I° injuries – show, that under the condition of an appropriate selection of the patients the usage of the therapy recommendation “act as usual” leads to very good long-term results. After six months only 5 of 162 patients (3.1%) interviewed by phone complained intermittent pain symptoms. Obviously the pain intensity was low enough in all patients as none of the patients used the telephone hotline to complain persisting pain symptoms and ask for further therapy measures. The general performance of physical therapy is under consideration of a chronification rate of 3.1% not justified.In case of persisting pain symptoms longer than two weeks and the possibly occurrence of associated functional deficits the therapy concept should be changed and adapted to the new situation. In this context additional active physical therapy measures seems quite meaningful. Concerning the healing prognosis the delay of two weeks until beginning physical therapy could be neglected in these patients as active physical measures relevant for healing normally could start at the earliest after 10 days. To get the general flexibility of changing therapy concepts a detailed and comprehensive initial consultation of the patient about the injury severity and the predicted healing process and possible complication seems to be very helpful.If the differentiation between patients with QTF I° and QTF II° injuries is not or not accurately performed, one has to fear that the general therapy recommendation “act as usual” leads to an increase of the chronification rate. In a therapy study with a mixed patient collective of QTF I° and II° patients, In the case of Germany, in which the study has been performed, the orienting economic analysis leads to following results. Under the assumption of ordering 18 therapy units on average of passive physiotherapy (23.60€) or active physiotherapy (42.40€) the therapy costs per patient add up to 424.80€ or 763.20€. In comparison to that the therapy recommendation “act as usual” causes no therapy costs. In Germany 2011 306.266 motor-vehicle related accidents with 323.380 minor injuries were registered . A detaiUnder consideration of the high frequency of QTF I° injuries in comparison to the total number of whiplash injuries – in this study 76.4% (359 out of 470) patients – the therapy recommendation “act as usual” in combination with an adapted pain treatment offers a huge potential of costs reduction. Nevertheless the therapy recommendation “act as usual” has up to now not been sufficiently established in the health systems for the treatment of QTF I° whiplash injuries. May be multi-centre studies assessing the socio-economic effects in the health systems and confirming the results of the exemplary economic analysis mentioned-above should be performed. Independently of that the knowledge of optimizing the treatment guidelines for QTF I° patients should be expanded into the general medicine of the health systems by improving the education of the physicians and therapists.General therapy recommendations do not cope with the specific therapeutic needs of mixed patient collectives after whiplash injuries. Based on medical and socio-economic reasons physical therapy should be formulated dependent of the severity of the sustained injury. Normally patients with whiplash injuries QTF I° do not need physical therapy. The therapy recommendation “act as usual” in combination with an adapted pain treatment is sufficient. An escalation of therapy measures should be reserved to patients with complicated healing processes.


This study was designed to investigate the impact of demographic and psychosocial factors on HSG pain and discomfort.Hysterosalpingography (HSG) is an important diagnostic procedure in the investigation of infertility. It is the radiographic delineation of uterine and tubal cavities and is part of the diagnostic evaluation of conjugal infertility.One hundred hysterosalpingography referrals were recruited for this study. Verbal detector scales were used to assess pain perception, Likert scales were used to assess the psychosocial variables, while visual analogue scales were used to assess discomfort. Pearson's correlations were conducted. Tests were two-tailed, with p < 0.05 indicating statistical significance.Some of the patients (34%) indicated that the administration of analgesics prior to the procedure reduced the pain and discomfort associated with the procedure. Mean ± standard deviation of pain and discomfort were 2.82 ± 0.77 and 6.36 ± 2.19 respectively. Age correlated significantly with pain perception , while pain correlated significantly with perception of discomfort .Age significantly correlated with pain. This is a factor that could be harnessed for clinical use. It is the radiographic delineation of uterine and tubal cavities and is part of the diagnostic evaluation of conjugal infertility.7 or both have been combined on the same scale.9 The medical literature considers comfort more in its absence, for instance in the assessment of discomfort in mammography,11 with discomfort regarded as the most painless version of pain. However, discomfort has also been defined in the medical world as a subjective, unpleasant feeling that the patient does not interpret as pain.12 Comfort is considered a multidimensional construct covering the physical, social, psychospiritual and environmental dimensions.13The difference between the notions of ‘pain’ and ‘discomfort’ has remained unclear when only one or the other has between measured,The enhancement of comfort is one of the primary goals of radiographers, nurses and radiologists carrying out hysterosalpingography . It is a common practice to prepare patients psychologically before the procedure. A good knowledge of the impact of demographic and psychosocial factors on HSG pain and discomfort would act as a good guide to radiographers, radiology nurses and radiologists. This study was designed to investigate the impact of demographic and psychosocial factors on HSG pain and discomfort. To the best of our knowledge, this work has never been done before.This study evaluated a convenience sample of one hundred (100) patients referred for HSG for the evaluation of infertility in two centres in southeast Nigeria from June 2007 to March 2008. Ethics approval and the patients’ consent were obtained. The traditional technique performed with a metal cannula was adopted for all the patients included in this study. The procedure was always performed in accordance with the ten-day rule. Exclusion factors included the use of any medication that increases or decreases neurological pain thresholds, and any disease process associated with increasing or decreasing the pain threshold . The patients underwent HSG via the metal cannula technique, with no anaesthesia being used. The technique consists of bimanual examination, followed by placement of the speculum, vaginal antisepsis, gripping of the anterior lip of the cervix with forceps, and coaptation of the metal cannula into the external cervical orifice for the injection of a hydro-soluble iodinated contrast medium (20 ml of 76% urografin). The contrast agent was introduced and radiographs were obtained. Each patient completed a questionnaire at the end of the procedure.The questionnaire contained three sections, A, B and C. Part A was designed to collect demographic information, e.g. age, academic qualification and occupation. Lower academic qualifications  were coded 1, while higher academic qualifications  were coded 2. Students and private sector-based patients were coded 3 (occupation), while public servants were coded 4. Part B of the questionnaire adopted ordinal scales. A four-point Likert format was used to measure psychosocial variables. The variables included the patients’ perceptions of the explanations of the procedure prior to the investigation, their fear of contagion, satisfaction with the procedure, the privacy provided, and time spent on the procedure. Strongly disagree was rated 1, disagree was rated 2, agree was rated 3 and strongly agree was rated 4. A four-point verbal descriptor scale (VDS) was used to assess the patients’ perceptions of pain during the procedure. Not painful at all was rated 1, painful was rated 2, very painful was rated 3 and extremely painful was rated 4. A ten-point visual analogue scale (VAS) of 1 to 10 was designed and used to assess the patients’ perceptions of discomfort during the procedure. A high score on the scale indicated a high level of discomfort and a score of 1 denoted no discomfort at all. Part C was an open-ended question that sought suggestions from the patients on how the pain and discomfort associated with the procedure could be reduced.For the statistical analysis, the test for normality was carried out using the three-sigma rule. The descriptive analysis involved the determination of the mean, standard deviation (SD), mode, median and skewness. In the inferential statistical analysis, Pearson's correlation was used to obtain the relationship between occupation, educational qualification and psychosocial variables. The content of comments made in part C of the questionnaire was analysed. The comments were subjected to theme analysis by grouping the themes to establish major areas of agreement. SPSS 7.5 software was used for analysis. All tests were performed with a 5% significant level.A total of one hundred (100) questionnaires was distributed and collected. The ages of the patients enrolled in this study ranged from 23 to 46, with a median age of 32. The mean age ± SD was 32.57 ± 6.05, while the modal age was 30. 52 patients (52%) had lower academic qualifications, while 48 (48%) had higher educational qualifications. 52 of the patients (52%) were students or based in the private sector, while 48 (48%) were public servants. In this study, pain perception correlated negatively and significantly with discomfort occasioned by HSG . Content analysis of part C (comments made by the patients) indicated that 34 patients (34%) believed that the administration of pain-relieving drugs  would reduce the pain and discomfort occasioned by this procedure. One patient (1%) believed that prayer would solve the problem, while two patients (2%) suggested that friendliness from the workers would ameliorate the pain and discomfort associated with the procedure. Three patients (3%) suggested that professionals should do rigorous research to find out how best the pain and discomfort associated with HSG could be controlled, while 60 patients (60%) made no comments at all.15 which are examinations used for the same purpose. The authors investigated the impact of demographic and psychosocial factors on pain and discomfort experienced during HSG.Hysterosalpingography remains one of the first steps in the evaluation of a woman for infertility. Most studies have shown that it is more painful than sonohysterosalpingography or outpatient hysteroscopy,16 which reported that women between 25 and 34 years of age constituted the highest number of referrals for hysterosalpingography. Varpular obtained a VAS value of 5.2 for pain experienced during HSG with the use of metal cannula.17 On a ten-point scale, this value translates to 2.08 on the four point scale (VDS) used in this study. This value (2.08) is in agreement with the pain perception reported in the present study, and falls within the range of the mean ± SD value of pain perception reported in this study. Time spent refers to the patients’ perception of a long time. Patients with higher codes  have a greater tendency to believe that they have spent a lot of time, as shown by the significant relationship between qualification and perception of time spent.The study has shown that the mean age ± SD of the women in this study was 32.57 ± 6.05, the median age was 32 and the modal age was 30. These values are in agreement with those in a previous study by Agwu and Okoye,None of the psychosocial variables correlated significantly with the perception of pain or discomfort. Educational qualification and occupation did not correlate significantly with pain and discomfort. A higher skewness (-0.402) value for discomfort than for pain indicates higher subjectivity and variability in the assessment of discomfort than of pain. Age was the only demographic factor that correlated significantly with pain . This implies that younger patients are more sensitive to pain and should be treated accordingly. It is therefore suggested that there should be an emphasis on pain management in the case of patients younger than the median age of 32 years.20 The current definition of pain, as proposed by the International Association for the Study of Pain (IASP), reads: ‘pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.’21 This definition identifies the complex and multidimensional experience of pain, where the patients’ physical, cognitive, emotional and behavioural characteristics mediate the pain experience.22 This multidimensional experience of pain is not in agreement with the present study, as all the psychosocial variables did not significantly correlate with pain. This difference could be the distinction between chronic and acute pain, as Katz22 considered the multidimensional nature of chronic pain.The modern paradigm of pain management has moved from the biomedical to the broader biopsychosocial approach, where pain mechanisms integrate input from sensory, emotional and cognitive systems.Some of the issues we were unable to examine in this study invite further research. One such question is the existence or otherwise of pain anticipation and the source of such anticipation: media, friends, websites or healthcare professionals. Another is the impact of the attitude of the staff towards discomfort and pain experienced during HSG, patients’ methods of coping with pain and the role of coping strategies. Rigorous research in this area, as suggested by some of the patients, and an improvement in the staff attitude towards the patients are also recommended. Another limitation in this study was that the patients were not given analgesics prior to the study in order to reduce pain as an aspect of patient care concern. It is hereby suggested this ethical and patient care aspect should be taken into account in future studies. This study has established that age negatively and significantly correlates with HSG pain, which is a factor that could be used in the clinical environment in relation to reassurance and patient care.


The pain score of patients was assessed using a visual analogue scale (VAS) at baseline, 15, 30, 45, and 60 minutes after administration. Of all 159 patients who were assessed for eligibility finally, the results of 120 patients were analyzed. There was no significant difference regarding age and gender between two groups. The baseline VAS score was not significantly different between two groups (P = 0.44). The Mean ± SD scores of two groups reduced 15 minutes after drug administration, but this decrease was significantly more in Group A compared with Group B (P = 0.02). This pattern continued in minutes 30, 45, and 60 of drug administration. Our results showed that desmopressin could be used as an effective adjuvant in acute renal colic pain management.The aim of this study was to compare analgesic effect of intramuscular (IM) sodium diclofenac and intranasal desmopressin combination with IM sodium diclofenac alone in patients with acute renal colic. In this randomized double-blind clinical trial, all patients aged 18 to 55 years who were diagnosed as acute renal colic and met the inclusion and exclusion criteria were randomized into two groups to receive 40  Pain is the most common presenting complaint in patients who present to the Emergency Department, which presents in 50–75% of all the patients . Renal cThe need for finding the best drug for renal colic pain management is still crucial. It has been suggested that decrease in diuresis by antidiuretic hormone helps to relieve the pain of renal colic immediately –6. DesmoThis study was conducted to compare the analgesic effects of intramuscular sodium diclofenac and intranasal desmopressin combination with intramuscular sodium diclofenac alone in patients with acute renal colic.This randomized double-blind clinical trial was carried out in the Emergency Department (ED) of Imam Khomeini Hospital, Ahvaz, Iran, from April 2014 to July 2014. All patients complaining of renal colic, aged between 18 and 55 years, presenting to the ED were assessed for the eligibility of the study.The diagnosis of renal colic was made based on chief compliant (flank pain), history and physical examination, and positive history of renal stone. The presence of renal stone was confirmed in all patients using ultrasound or computed tomography.Patients with hypertension, coronary artery disease, rhinitis, influenza, coagulopathy, anticoagulant therapy, peptic ulcer disease, asthma, kidney failure, liver failure, pregnancy, use of analgesics within 4 hours and Alpha blockers before admission, history of addiction, surgery on the kidney or ureter, and fluids therapy immediately before admission were excluded. During the study, if a patient could not bear the pain and did not want to continue, he/she was excluded.Eligible patients were randomized between two groups (A and B) in a 1 : 1 ratio using a computer-generated code. The identities of the study drugs were recorded in a document, folded four times, and then covered for allocation concealment. When a patient was enrolled in the trial, a study nurse retrieved one of the drugs from a box. The medication was prepared by the study nurse and administered by the second nurse who was blinded to the purpose of the intervention. The study drugs were identical in color and appearance; therefore, the patients and study physicians were blinded to identity.μg of intranasal desmopressin spray  equal to 4 puffs of available products  combined with 75 mg intramuscular sodium diclofenac  was administered. Group B received 75 mg intramuscular sodium diclofenac  and NACL 0.65%  intranasal spray .First, using 10-centimeter visual analog scale (VAS), all participants were assessed for severity of pain (10 = the worst possible level of pain and 1 = painless). For this purpose, the emergency physician showed the printed VAS ruler to the patients and asked them to show the number that represents their perception of their current pain. Then in Group A, 40 All participants in both groups were assessed for severity of pain according to VAS standards 15, 30, 45, and 60 minutes after drug administration, and differences in pain level of 2 or more VAS units were considered significant. After 30 minutes, if severity of pain was equal to or more than 5 VAS units, 5 mg morphine sulfate was administered intravenously to the patient as rescue therapy. If any degree of pain persisted after minute 60, an additional dose of morphine sulfate was administered.Before commencement of the study, we obtained the code of ethics numbered ETH-359 from the Ethical Committee of Ahvaz Jundishapur University of Medical Sciences, and every stage of the study was in accordance with the Helsinki Declaration 1975. Written consent was obtained from all participating patients, and confidentiality of patient's personal details was maintained. This study was registered at Iran's Clinical Trials Registration Centre, and the relevant code was obtained.Statistical Analysis. To consider α = 0.05, β = 0.2, power = 80%, and the final differences between the two groups at least 2 scores on VAS, the sample size was calculated at least 40 in each group. Continuous variables were summarized as Mean ± SD and categorical variables as ratios. Two-tailed independent t-test was carried out to compare quantitative variables with normal distribution and chi-square was done for comparing qualitative ones.Initially 159 potential study candidates were assessed for eligibility; however, 36 subjects did not meet the inclusion and exclusion criteria. Three participants refused to finish the study. Eventually, 120 (60 in each group) patients were allocated randomly between the two groups and data from these participants were analyzed.Baseline characteristics of two groups participants are presented in P value = 0.44).There was no significant difference regarding baseline VAS pain score (Mean ± SD) between two groups . This pattern continued in minute 30, minute 45, and minute 60 of drug administration  is available, which is administered into a nostril. The biphasic half-lives of intranasal desmopressin were 7.8 and 75.5 minutes for the fast and slow phases, respectively. Usually only a single dose of 40 μg/4 puffs of intranasal desmopressin may be prescribed [Desmopressin is the first line of replacement therapy in the nocturnal enuresis and central diabetes insipidus –9. Likelescribed .Our results showed that the combination of nasal desmopressin and IM diclofenac is more effective than IM diclofenac alone in acute renal colic pain reduction. This difference started 15 minutes after drug administration and was maintained during 60 minutes of follow-up.The pain generated by renal colic is primarily caused by the dilation, stretching, and spasm caused by the acute ureteral obstruction. In the ureter, an increase in proximal peristalsis through activation of intrinsic ureteral pacemakers may contribute to the perception of pain. Muscle spasm, increased proximal peristalsis, local inflammation, irritation, and edema at the site of obstruction may contribute to the development of pain through chemoreceptor activation and stretching of submucosal free nerve endings. Mentioned mechanisms  were considered reasonable causes for effective role of desmopressin in our study.In 1994, El-Sherif et al. [Constantinides et al., 1998, evaluated desmopressin efficacy in 108 renal colic patients. Over fifty-three percent of their patients respond after 30 minutes. Others received prostaglandin synthesis inhibitors or pethidine for pain relief. They concluded that desmopressin could be used for renal colic pain management .Lopes et al., 2001, compared the efficacy of nasal desmopressin spray with IM diclofenac in three different groups . Their results revealed that pain score reduction was equal in all groups 10 and 20 minutes after drug administration, but at minute 30 there was a slight increase in pain score in the first group. They did not follow patients after minute 30, but in our study pain reduction decreased significantly in desmopressin-diclofenac combination group since 15 minutes after administration and during one-hour follow-up this difference was maintained .μg of intranasal desmopressin in combination with 20 mg intramuscular hyoscine N-butyl bromide. In the first group, the mean of pain level showed a decrease after 30 minutes but further decreasing did not occur; however, in the second group, the pain consistently decreased and the mean after 60 minutes was significantly decreased. In another study, Roshani et al. [μg, plus diclofenac sodium suppository 100 mg, and patients in the second group received diclofenac sodium suppository 100 mg plus a placebo spray consisting of normal saline 0.9%. They showed that intranasal desmopressin plus diclofenac sodium suppository caused prompt pain relief with significant decreases in pain scores after 15 and 30 minutes and suggested that intranasal desmopressin spray is a useful supplemental therapy for renal colic in combination with NSAIDs, especially to reduce the use of opioids. In 2012, Moosavi Beladi et al. [In 2010, Kheirollahi et al. , in a clOn the other hand, Kumar et al.  reportedAlthough several studies have evaluated the desmopressin efficacy in renal colic pain management, there is a disagreement in their results.Desmopressin has several advantages, such as ease of administration, simplicity of delivery, apparent lack of side effects, and rapid action, which makes it suitable for ambulatory use. It seems that desmopressin is a promising alternative or adjunct to analgesics in patients with acute renal colic, especially in cases that there is contraindication for narcotics or resistant pain to the standard medical therapy. Besides, its biphasic half-life is a considerable advantage. Not only does it have rapid onset effect, but also these analgesic effects maintain for a long duration.Our results showed that desmopressin could be used as an effective adjuvant in acute renal colic pain management.


The place of opioids in the management of chronic, non-cancer pain is limited. Even so their use is escalating, leading to concerns that patients are prescribed strong opioids inappropriately and alternatives to medication are under-used. We aimed to understand the processes which bring about and perpetuate long-term prescribing of opioids for chronic, non-cancer pain.We held semi-structured interviews with patients and focus groups with general practitioners (GPs). Participants included 23 patients currently prescribed long-term opioids and 15 GPs from Leeds and Bradford, United Kingdom (UK). We used a grounded approach to the analysis of transcripts.Patients are driven by the needs for pain relief, explanation, and improvement or maintenance of quality of life. GPs’ responses are shaped by how UK general practice is organised, available therapeutic choices and their expertise in managing chronic pain, especially when facing diagnostic uncertainty or when their own approach is at odds with the patient’s wishes. Four features of the resulting transaction between patients and doctors influence prescribing: lack of clarity of strategy, including the risk of any plans being subverted by urgent demands; lack of certainty about locus of control in decision-making, especially in relation to prescribing; continuity in the doctor-patient relationship; and mutuality and trust.Problematic prescribing occurs when patients experience repeated consultations that do not meet their needs and GPs feel unable to negotiate alternative approaches to treatment. Therapeutic short-termism is perpetuated by inconsistent clinical encounters and the absence of mutually-agreed formulations of underlying problems and plans of action. Apart from commissioning improved access to appropriate specialist services, general practices should also consider how they manage problematic opioid prescribing and be prepared to set boundaries with patients. Opioids are commonly prescribed for chronic, non-cancer pain despite limited evidence of effectiveness and frequent adverse effects –4. ThereThe therapeutic benefit of opioids in musculoskeletal pain is established for short but not long term use , 10, 12 Patients with chronic pain face challenges, such as explaining and legitimising their symptoms , whilst We interviewed patients and GPs about their experiences, beliefs and expectations of analgesia prescribing, to improve understanding of how problematic long-term opioid prescribing becomes established.A qualitative study, comprising semi-structured interviews and focus groups, in general practices across Leeds and Bradford, cities in the North of England.Thirty-seven (23 %) of 158 general practices approached expressed an interest. To ensure diversity in their experiences, we sampled patients from practices with high and low opioid prescribing levels. Electronic searches identified patients aged 18 and over, with a current repeat prescription for either a strong opioid (e.g. morphine) or a weak opioid (e.g. codeine). We excluded patients with cancer or cognitive impairment. Each practice invited up to 60 patients by letter to contact the study team. As recruitment progressed, we purposively sampled by sex, age, recent significant changes in opioid prescriptions, opioid strength, the presence of coded mental health problems and ethnicity in order to maximise the range of relevant attributes.We invited individual GPs from the 37 practices to take part in a focus group held in their locality, seeking one GP from each practice.Semi-structured interviews (by CM and LZ) with individual patients covered accounts of their prescribing histories, experiences of treatment, and hopes and expectations (Appendices Early patient interviews informed the development of patient vignettes to prompt the subsequent focus group discussions with GPs (facilitated by RF and CM). The two vignettes illustrated patients experiencing suboptimal pain control on opioids. We prompted discussion on experiences and expectations of the initiation and maintenance of opioid prescribing, management options, perceived ‘red flags’ for long-term opioid use and experiences of trying to reduce prescribing. All interviews and focus groups were audio taped and transcribed verbatim following written consent.Constant comparison was used to analyse transcriptions. Analysis involved deconstructing each transcript to identify primary categories (open coding). These categories were compared with others within and across transcripts, followed by cross-linking of categories to generate new meanings and concepts  then cross-linking of concepts to generate themes (selective coding) . InterviData collection and analysis proceeded iteratively, with focus group findings informing later patient interviews, allowing progressive focusing on key themes to explain findings. The wider study team also read selected transcripts before discussing emerging findings and analyses. From the two perspectives (patient and GP) we identified, we derived an account of the main features of transactions between patients and GPs and subsequent prescribing decisions.The study was approved by Yorkshire and the Humber (Humber Bridge) NRES Committee 12/YH/0109.Sixty-one out of 391 invited patients expressed an interest. We subsequently interviewed 23 patients  from 13 practices  participated in two focus groups. One GP had agreed to participate but subsequently did not attend. Participants had on average 10 years’ experience as GPs (range two to 36 years) and a median list size of 7500 patients (2400 to 25000 patients). Two GPs had special interests in pain management, one in mental health and one in palliative care.‘[I wanted the GP] just to relieve the pain really… more or less just give me the medication to take the pain away. Nothing other than that.’ Patients sought pain relief, an explanation of their symptoms and to improve or maintain quality of life. Such hopes and expectations often continued to be unmet amongst those patients we interviewed. Sometimes this was because expectations of achievable pain relief were unrealistic:‘… and from what I’ve read up, because I like to, sort of, keep on top of things, that it’s an opium based drug, so you will build up some tolerance and you will build up [becomes tearful] And you will potentially become sort of addicted to it, if you like.’ Patients repeatedly consulted with poorly controlled pain despite continuing or even increased doses and strengths of pain killers. However, they often recognised that they had to balance any benefits from pain relief with the adverse effects of opioids. Hopes for pain relief were tempered by fears about adverse effects of treatment escalation, particularly opioid dependence:‘Well it was like a challenge for me…because all they did really was to tell me to lose weight, it’s the menopause, and that was it…and I kept going to the GP because I knew something wasn’t right. But I had the stamina to say well I know something’s not right, I want to be seen.’ Patients sought an explanation for their symptoms and often struggled to receive one. The patients we interviewed often described complex narratives, sometimes relating the onset of their symptoms to specific events  and often requiring multiple investigations and consultations with primary and secondary care clinicians. They picked up partial or even contradictory explanations for their symptoms; diagnostic labels such as osteoarthritis, fibromyalgia and hyper-mobility syndrome did not appear to sufficiently capture their suffering. Doctors’ explanations which attributed poorly controlled pain symptoms to lifestyle factors or life events were received with or even fuelled scepticism:‘I don’t know how many times I’ve sat and I’ve just sat and cried and said, I’ve had enough, you know. And before I got on the gabapentin I just sat in the GP’s office in floods of tears like a lumbering idiot and said if you can’t take this pain away from my legs just chop them off, because it’s just 24/7…’ Patients’ abilities to cope with pain varied over time, and they were driven to seek help when medication or other coping measures no longer work and their pain interferes with their usual activities. The centrality of quality of life to patients was apparent in their distress when seeking help from GPs:Four themes characterised not just the views of patients or GPs, but some feature of the transactions between them.Absence of a shared management plan. First and most importantly, the management of patients with chronic pain often unfolded in the absence of a shared long-term management plan so that prescribing occurred as a default reaction. Prescribing decisions for unfamiliar patients, often with long and complex pain histories, were made within the time constraints of routine consultations:‘They’ll be down for their medication review but they’ll say, I’m here for my medication review, you’ll spend some time doing the tablets. Oh and whilst I’m here I’ve got this rash, I’ve got this, whatever it is. So that automatically then reduces the time you can actually spend looking at all of their medication which might include their painkillers.’ Pain management was often marginalised in the context of co-morbidities, especially given the absence of clear treatment goals compared with other long-term conditions, such as diabetes.‘It seems to me that when I got to a certain level [300mcg Fentanyl patch], it was almost like she’d [the GP] not realised that she’d gotten me up to that....and so now all we do is work on getting that level down.’ Patients could also receive opioid prescriptions after telephone requests, when GPs were juggling various other urgent calls and queries competing for their time. GPs resorted to the compromise of prescribing further opioids without formal medication reviews. These short-term fixes accumulated so that repeated prescriptions or escalating strengths of opioid became the norm for patients until either party realised that the clinical management approach was not working. At this point, safety concerns may have been raised or the GP may have admitted to running out of ideas on further management:‘… there’s something about us not saying to patients often enough, you know, these are addictive, take them when you’re in pain. Because everybody always says, you need to take them four times a day because if you break that… your pain is going to come through. So we’re telling them that on the one side and then on the other side we’re saying, you’ve got to stop taking it as soon as you’re not in any pain because otherwise you’re going to be hooked on them and your use is going to escalate up.’ GPs were aware of the limitations of prescribed opioids, which then compromised their abilities to formulate coherent management plans. They expressed some uncertainty about how to prescribe them appropriately and were aware of giving conflicting advice to patients on balancing pain relief against the risks of tolerance and addiction:Locating control and responsibility for change. Second, we recognised a discussion about where perceived control resided and who has the ability to make change. Sometimes patients positioned control with their GPs:‘And I know the doctors know what they are doing, I suppose, but you don’t know whether to say ‘I think these patches are working, can you up it?’ ‘He [the GP] said what exactly do you want me to do? You've pretty much been on everything so there is nothing for you to do. There is nothing for you to go on to. And I was like well what exactly am I doing coming off [strong opioids] when you've got nothing to put me on to?' At other times, patients felt responsible for controlling the use of prescribed medication. Not infrequently, neither party felt in control and non-pharmacological approaches were limited by resource constraints:‘…every time I send somebody to chronic pain [clinic] they come out with more medication, or injections.’ One response to this mutual lack of control was to refer patients on for specialist assessment and management, usually to pain clinics. Access to appropriate pain services, especially those dealing with behavioural and psychosocial aspects of chronic pain management, was limited and GPs felt under pressure to do something whilst patients waited, usually increasing opioid therapy. Referrals allowed some alleviation of clinical responsibility but were made more in hope than in expectation.‘Well all they do really is refer me to see a specialist, which was what they did in the first place, referred me to see a specialist and give me tablets… It’s like you are banging your head against the wall, you get fed up of going there… it’s a waste of my time, it’s a waste of their time because they’re not interested…’ Patients could go through several cycles of referrals and new treatments, and of building up hopes and being disappointed, so that each cycle reinforced a sense of futility.Long term prescribing often continued because of a perceived lack of alternative options, with neither party feeling in control nor achieving satisfactory outcomes.Continuity of care. Third, GPs were aware of the needs to get to grips with the key issues in patient narratives and to explore beliefs or behaviours which influenced their experience of pain. Some responded by trying to establish continuity through investing more time in patients with chronic pain.‘I think it’s good to take ownership…, because it’s that collusion of anonymity thing isn’t it? As soon as someone gets sort of uncomfortable they will shift to a different prescriber and they will push them along a certain course and they’ll go, I don’t like that, and they’ll go to a different one. And I honestly think it’s like a ship without a rudder and it’s just going round and round in circles.’ ‘Would you feel guilty, you know, if you were bringing back a patient each week? And I think I’d have a bit of that because I think you don’t want to appear as if you’re seeing someone over and over again to your colleagues. I think that… certainly with me that I don’t want to be seen as that doctor that brings someone back every week…’ Patients also highlighted problems with the lack of continuity and did not feel their needs could be properly addressed if their doctors were unfamiliar with their records. However, taking responsibility and trying to establish continuity had two potential drawbacks. It had implications for practice workload and might be perceived as unfair by colleagues because it reduced availability to see other patients:‘She’s [the GP] known me for years and years and she, she’s really nice and, but sometimes, in a way, knowing them can be worse, because you don’t tend to question their judgement, you know, because you don’t want to offend, if you get what I mean?’ Continuity could also result in stagnation, with losses of impetus and ideas for change, making it difficult for GPs or patients to question decisions:One GP described her discomfort with consultations dealing with chronic pain and acknowledged that she felt better equipped to deal with different problems. Therefore continuity appeared more likely to be productive if GPs possessed interests and skills in supporting patients with chronic pain.Mutuality and trust in the relationship. Finally, mutuality and trust between patients and GPs provided a platform for negotiating wider aspects of the relationship and considering more holistic approaches to pain management. However, establishing some level of trust was difficult when GPs had formed fixed, negative attitudes towards patients. GPs anticipated that consultations with certain patients were going to be problematic; this suggested that the problems resided as much within the characteristics of the patient as in the pain itself.‘I’ve got different responses to different patients I’ve realised just thinking about them. There’s one or two that my heart just goes, “oh dear, here we go…” because I know it’s going to be a tough consultation.’ ‘They’ve come in to get more medication and that’s their agenda. And you’re sitting there with this other agenda which is, you’re taking too many tablets and I’ve got to now try and address that with you. That is like a completely… they’re opposed completely so you know, they’ve come in with one thing and they know it’s going to be a battle, they’ve already got their hackles up.’ There could be significant resistance to suggestions of reducing or stopping opioid treatment:‘And then once you’ve got to that point and they’re still struggling with pain it’s almost having that conversation where you can then start to say, well maybe it’s not completely physical…’ GPs often suspected they were faced with patients being managed for an incompletely formulated problem, especially in the presence of known or suspected mental health problems. Although they recognised the dangers of continuing or escalating opioid prescribing in such circumstances, GPs said that prescribing represented a means to establish trust so that non-pharmacological approaches could be considered then or at a later point.Some recognised this as a sub-optimal strategy as biopsychosocial approaches should ideally have been addressed at an earlier stage.Patient needs for pain relief, an explanation of their symptoms and help to improve or maintain their quality of life were often unmet amongst those we interviewed. All GPs expressed dissatisfaction with some aspect of their approach to chronic pain management, be it with their own consultation skills, the limitations of the drugs they were prescribing, or the constraints of the clinical environment. The accounts in this study have highlighted problematic long-term prescribing, but we recognise that there will be many clinical encounters involving the non-problematic management of patients well controlled on a stable opioid prescription that is appropriate to their condition. We encountered a now-familiar story of dissatisfaction on both sides – patients experiencing repeated consultations that did not meet their needs, and GPs describing frustration with this state of affairs and yet with no clear idea of how to break out of it.The resulting transaction was an impasse with the features of failure of satisfactory management of a long-term condition. The most striking manifestation of this failure was that both patients and clinicians recognised that they did not share a mutually-agreed plan of action, instead negotiating change through a series of short-term, often emotionally-charged consultations.Three other themes in the clinical encounter confirm this formulation. First is an awareness of failure to resolve the tension between patient-centredness and evidence-based practice , generatGiven these circumstances, the continued prescription of an opioid can seem like the least-worst option for both parties, but becomes the main – if unintended – mechanism for preventing resolution. It creates an atmosphere of pseudo-mutuality and pseudo-control for both parties – the patient has got what they requested and the doctor has acted in role. The medication can reduce symptoms of distress and anxiety, at least transiently. And the act of giving and receiving the prescription can look like active engagement with the main dilemma but is in fact a form of avoidance, one of a number of strategies employed as means of not getting uncomfortable uncertainties and differences of opinion into the open .We studied a sample of patients which may be atypical  although we did achieve some balance in trajectories. An alternative of asking GPs to select patients could have resulted in a different selection bias. There was likely under-representation of patients from black and minority ethnic groups. We also studied self-selected GPs who may have had greater interest in this issue, although our invitation specifically sought GPs with a range of interests and only a minority in our sample self-declared interests in pain. We studied GPs and patients in one geographical area within the UK National Health Service; however, similar concerns about prescribing decisions and actions are emerging elsewhere in other healthcare systems . Our undOur patient accounts are broadly consistent with those in a recent meta-ethnography of qualitative studies, particularly in the ‘adversarial struggle’ patients faced in constructing explanations for their symptoms and negotiating the healthcare system . SimilarEsquibel and Borkan also compared the experiences of primary care physicians and patients in one US Family Care Center, separately interviewing each in 21 dyads . There wOur findings suggest that GPs would be receptive to guidance on and support with the management of chronic, non-cancer pain and opioid prescribing. The content of educational interventions should draw upon existing good practice guidance , and preFor those already prescribed opioids, our findings indicate the need for a systematic approach to each patient that is not negotiated ‘on the hoof’ during individual consultations. A first step in primary care is practice-level reviewing of prescribing and potential non-pharmacological approaches to chronic pain management; a plan can then be formulated that is not over-influenced by the short-term consultation-by-consultation approach. Consistency in delivering this plan requires clear communication, including agreement of a shared aim within the general practice team and informational continuity for individual patients. At the same time, it cannot be assumed that relational continuity will work in the patient’s best interests, given the risks of perpetuation of ineffective clinical strategies . TherefoGeneral practice strategies to prevent or manage problematic opioid prescribing also need support from commissioned specialist services which should include non-drug interventions. There are transferable elements of collaborative care approaches, effective for other long term conditions, which enable active communication between GPs and specialists to monitor and plan patient care . HoweverProblematic prescribing occurs when patients experience repeated consultations that do not meet their needs and GPs feel unable to negotiate alternative approaches to treatment. Therapeutic short-termism is perpetuated by inconsistent clinical encounters and the absence of mutually-agreed formulations of underlying problems and plans of action. Apart from commissioning improved access to appropriate specialist services, general practices should also consider how they manage problematic opioid prescribing and be prepared to set boundaries with patients.