Prescribing opioids for postoperative pain has increased steadily, and hand surgery has been no exception. Current hand surgery literature does not describe the efficacy of pain self-management postoperatively. The purpose of this study is to describe our experience with over-the-counter (OTC), narcotic-free, postoperative pain management.We have done a retrospective chart review at an academic tertiary-care facility. Patients who underwent soft-tissue hand surgery in an office-based procedure room between January 1, 2018, and March 1, 2019, done using wide-awake local anesthesia only with no tourniquet were included.Eighty-one continuous patients met the inclusion and exclusion criteria. The procedures included carpal tunnel release, cubital tunnel release, trigger finger release, first dorsal compartment release, dorsal wrist ganglion cyst excision, hand or finger mass excision, percutaneous needle fasciotomy, flexor tendon repair, and extensor tendon repair. Two patients (2.4%) received a prescription for pain medication within 1 day and 4 within 1 week after discharge . Nine patients were already on chronic narcotics, and four were on short-term narcotics before the surgery date. No other patients requested or received opioid prescriptions after surgery, and no complaints were reported.This study indicates that patients can successfully self-manage their postoperative pain with OTC analgesics. They rarely request prescriptions for pain control after soft-tissue hand surgery. Our findings support current literature suggesting that narcotic prescriptions can be eliminated in select hand and upper extremity procedures and suggest that OTC postoperative pain management is sufficient. The purpose of this study is to describe our experience with over-the-counter (OTC), narcotic-free, postoperative pain management in a continuous cohort of 81 patients who underwent soft-tissue hand surgery in an office-based setting over a 14-month period.A retrospective chart review at an academic tertiary-care facility was done after Institutional Review Board approval was granted; patient consent was not required. We included all patients who underwent soft-tissue hand surgery by the author, in an office-based procedure room between January 1, 2018, and March 1, 2019. All procedures were done using wide-awake, local anesthesia only, with no tourniquet (WALANT). We excluded patients who received a prescription of scheduled narcotic pain medications on the day of surgery.All patients received pain management counseling on three occasions: the first visit during the surgical consent process, just before the procedure before the administration of local anesthesia, and during the procedure itself. The counseling was verbal and was provided by the attending surgeon: Patients were educated that the planned surgery was a minor procedure done under local anesthesia that did not require sedation or other forms of anesthesia. The patients were educated that the procedure is well tolerated by most patients and does not typically require prescription analgesics. The patients were asked to use the OTC analgesics of their choice and to follow the instructions provided on the packages. Acetaminophen and ibuprofen were provided as examples. We did not make any solid recommendation regarding frequency nor dosage other than following label instructions. Patients were scheduled to follow-up within 2 weeks postoperatively and encouraged to contact the surgeon earlier if necessary. Patients were provided with a variety of methods to contact the office, if needed, before their first postoperative visit. They included phone calls, e-mails, and a patient-portal mobile app. We reviewed pain medication prescriptions provided to the patient in the perioperative period, if any, from other providers. This information included all documented prescriptions within the electronic medical record  and data from a multistate database opioid monitoring system. We documented chronic narcotic prescriptions and recent preoperative narcotic prescriptions (within 2 weeks before surgery date) and postoperative narcotic prescriptions (2 weeks after the surgery date). The electronic medical records for all documented communications  during the 2-week postoperative period were reviewed.The primary outcome for this study was patient receipt of narcotic or non-narcotic analgesic prescriptions after they were discharged. Secondary outcomes included timing of those prescriptions and whether there were any documented complaints regarding pain management.Eighty-one continuous patients met the inclusion and exclusion criteria. Fifty-two patients were women, and 29 patients were men. The average age on the day of surgery was 53 years (range 17 to 82 years). The total number of procedures was 129, done on 97 upper extremities (50 on the right and 47 on the left), over 84 unique procedure visits. These include multiple procedures including bilateral procedures: 16 procedures were bilateral and included 13 done simultaneously and three done on different dates.The procedures included carpal tunnel release, cubital tunnel release, trigger finger release, first dorsal compartment release, dorsal wrist ganglion cyst excision, hand or finger mass excision, percutaneous needle fasciotomy, flexor tendon repair, and extensor tendon repair Table . Carpal Nine patients (10.7%) were already on chronic analgesics, and four (4.8%) had recent prescriptions for analgesics before the day of surgery. Of the 71 remaining patient visits with no preoperative analgesics, two patients (2.8%) received a prescription for pain medication on the first postoperative day. Two other patients received a prescription for pain medication within 1 week (on the third and fifth days) for a total of four patients (5.6%). It is not clear whether the two delayed analgesic prescriptions were for postoperative pain or other reasons. No other patients requested or received analgesic prescriptions after their surgeries, and no complaints were filed.11The United States consumes 80% of the global opioid supply and 99% of the hydrocodone supply, which makes hydrocodone with acetaminophen the most commonly prescribed medication.12 Many physicians, including most surgeons, have not received pain management training in narcotic prescribing. Physicians were asked to address pain as a “fifth vital sign” when, in fact, it was a symptom.13 Many surgeons do not know how much to prescribe or how much is actually consumed.13 Consequently, surgeons adopted standardized prescription routines without particular attention to the risks of drug dependence or diversion.14 They also adopted the same amount of narcotics their mentors used to prescribe.14Currently, there is no standardized education nor established guidelines for postoperative pain management.14 This trend led several surgical fields to question the necessity of postoperative opioids in outpatient surgery including breast surgery, hernia repair, and laparoscopic cholecystectomy.7Conversely, many patients report mild, tolerable pain after minor procedures and leave their narcotic prescriptions unfilled.16; in fact, hand surgery patients receive two to five times more opioids than they consume.3–5 The greatest consumption happens on day 0 and postoperative day 1, and the median for total days of consumption is 2 to 5 days.7These same characteristics equally apply to hand surgery. As many as 59% to 76% of hand surgery patients receive opioid prescriptions2–6789 Distal radius fracture patients consume 16 pills or less, on average.9 Shoulder and elbow surgeries require a mean of 11 to 22 pills for 3 to 5 days.3 Patients, however, receive a mean total of 24 pills, frequently in the form of standardized 30-tablet opioid prescriptions.14Current hand surgery literature suggests that patients consume 10 or fewer doses of analgesics regardless of what the analgesic is.7 Ilyas et al.6 found no statistical difference in worst daily pain levels or pill consumption after surgery between opioid and nonopioid groups. The patients “overwhelmingly agreed” that 10 pills were enough, although they were not aware what analgesics they received. The authors concluded that, no matter what analgesic is used, no more than five to 10 pills should be prescribed. Weinheimer et al.7 showed no difference in the average Visual Analog Score and time until pain-free (a median of 3 to 5 days). Of note, most procedures in these studies were done under local anesthesia7 which may present a confounding factor. Our surgeries were done exclusively under local anesthesia (WALANT) which facilitates surgeon-patient interaction and intraoperative counseling. It may also avoid any perioperative discomfort due to general anesthesia and tourniquet pain that may negatively affect comfort in the recovery room and pain expectations postoperatively. It remains to be seen whether the choice of local anesthesia affects pain perception and analgesic consumption.Two recent prospective, randomized, double-blinded studies confirmed equivalent pain control between narcotics and non-narcotic analgesics for soft-tissue hand surgery.9 Patients were satisfied with the amount and potency of the prescribed analgesics regardless of which one it was.6 In one study, two of the five patients who requested a stronger pain medication were already on opioids and did not receive any more.6 In another study, requests for rescue opioid medication were the same in opioid and nonopioid groups.7 Our results are compatible  and suggest that nonopioid analgesic prescriptions may not even be necessary.Refill requests are uncommon irrespective of whether an opioid was prescribed initially or not (2% to 7%).17 Specific to hand surgery, 13% of opioid-naive patients continue to fill opioid prescriptions beyond 90 days postoperatively.18The probability of long-term opioid use increases sharply in the first days of opioid therapy, particularly after 5 days.1–7 By limiting the frequency and quantity of opioids prescribed, physicians could have a direct and positive effect on the problem of opioid abuse.7Sixty-seven to 92% of patients reported unused opioids, which corresponded to 42% to 71% of unused opioid pills. This overprescription creates an opportunity for drug diversion.1 and those who expect more pain have more pain.19 For this reason, counseling is a critical part of pain management.20 Patients counseled on the day of and the first day after surgery consume markedly fewer opioid pills yet experience no more pain than those who were not counseled.20 Setting patient expectations is a powerful way to decrease the prescribing and use of opioids.14 When counseled that a nonopioid regimen was a reasonable alternative, a notable number of patients elected to avoid opioids.7 Of 92 patients who met criteria to enroll for a blinded study comparing opioid and nonopioid postoperative pain management, only one patient (1.1%) declined for fear of inadequate postoperative analgesia, whereas 19 patients (21%) declined because they preferred not be exposed to narcotics.7 These findings suggest that, given a choice, patients may elect not to receive any narcotics which leads to the question of whether prescribing physicians give patients that choice.Patients anticipate more pain than they actually report postoperatively,6 However, this practice comes at a cost.Surgeons choose opioid pain management for various reasons including concerns of undertreatment, avoiding patient complaints, and limiting early requests for refills.There are several opportunities for counseling during surgical patient care: on the day the patient decides to have surgery, just before surgery, during surgery (an advantage of wide-awake anesthesia), and immediately after surgery. The discussion should include the concept of pain and being pain-free, as well as expectations regarding analgesic consumption including the need, benefits, and risks of including/excluding opioids, supported by current literature and surgeon experience. The surgeon emphasizes that the goal of pain management does not include being pain-free, but that tolerable pain is expected and adequately controlled.There are a few limitations to this study. First, there was no control group. We are, however, confident, and this study confirmed that narcotic prescriptions are not necessary for most patients and find it ethically challenging to add a control group just for comparison. We have adopted narcotic-free pain management for all soft-tissue procedures done under WALANT as a standard of care for our practice. Second, some of the patients were already on analgesics before surgery. None of them received extra prescriptions for acute pain. Discounting those patients, 5.6% received postoperative prescriptions. Of those, only half of them (2.8%) received prescriptions within 2 days when pain management is most needed. We are not sure of the reason the delayed two prescriptions were given. Third, we cannot rule out the possibility of consuming previously unused or diverted analgesics.In review, however, this study confirms that no new prescriptions were provided for the purpose of the procedures, and very few patients requested them. There were no complaints documented.This study indicates that patient self-management with OTC analgesics was effective and rarely led to requests for rescue analgesic prescriptions. It confirms the current literature regarding the limited need for opioid prescriptions after soft-tissue hand surgery. Eliminating the use of opioid analgesics may be appropriate with adequate patient education and setting expectations and may improve patient satisfaction by reducing short-term side effects; it may also decrease misuse and the overall strain on the healthcare system. This study supports the elimination of opioid prescriptions altogether in select hand surgical procedures, and we have adopted this standard for office-based hand surgery.


Chronic low back pain (CLBP) arising from degenerative disc disease continues to be a challenging clinical and diagnostic problem whether treated with nonsurgical, pain intervention, or motion-preserving stabilization and arthrodesis.  Fourteen patients with CLBP, greater than 6 months, unresponsive to at least 4 months of conservative care were enrolled. All patients were treated successfully following screening using MRI findings of Modic type I or II changes and positive confirmatory provocative discography to determine the affected levels. All patients underwent ablation of the basivertebral nerve (BVN) using 1414 nm Nd:YAG laser-assisted energy guided in a transforaminal epiduroscopic approach. Macnab's criteria and visual analog scale (VAS) score were collected retrospectively at each follow-up interval. P < 0.01). As per Macnab's criteria, seven patients (50%) had excellent, six patients (42.85%) had good, and one patient (7.14%) had fair outcomes.  The mean age was 46 ± 9.95 years. The mean symptoms duration was 21.21 ± 21.87 months. The mean follow-up was 15.3 ± 2.67 months. The preoperative VAS score of 7.79 ± 0.97 changed to 1.92 ± 1.38, postoperatively  appears to be a promising option in carefully selected patients with CLBP associated with the Modic changes. Chronic low back pain (CLBP) is a serious medico-social problem and a cause of disability. According to the United States National Center for Health Statistics reports, 14% of new hospital visits are patients with chronic low back pain. The expense of treating low back pain is over $100 billion per year . In caseThe Modic change is closely associated with low back pain . A recenAlthough a few number of patients need surgical interventions, most of them get better spontaneously with conservative management without much worsening in the middle age. Treatment of CLBP associated with Modic changes has not been established yet. We have treated this condition with the transforaminal epiduroscopic approach  with lasPatients with isolated CLBP and type 1 or type 2 Modic changes on MRI for more than 6 months' duration that was nonresponsive to at least 3 months of conservative care were analyzed in this single-center retrospective observational study to evaluate the preliminary safety and effectiveness of BVN ablation for the treatment of CLBP with Modic changes.No specific course of conservative care was mandated before enrollment. Exclusion criteria included were Modic changes without CLBP, spondylolisthesis, scoliosis, history of spinal infection, and prior spinal malignancy. Patients who had radicular symptoms were also excluded. The study was also limited to the L2, L3, L4, L5, and S1 vertebrae. Patients with the identified pathology at more cephalad levels were excluded. Determination of the treatment level(s) was made by clear evidence of Modic type 1 or type 2 changes on MRI and by provocative discography.Treatment was limited to two or three contiguous vertebral bodies representing one or two motion segments, respectively. A detailed history and physical examination were performed on each patient to exclude origins of pain such as sacroiliac joint, hip, myofascial, genitourinary, gastrointestinal, or gynecologic sources.We performed 3 steps of provocation tests to check the Modic changes as the source of pain as follows: (1) preoperative provocative discography, (2) intraoperative laser provocation into the basivertebral nerve of the vertebral body with Modic changes, and (3) intraoperative relief of pain assessment by laser reprovocation of the same painful area after completion of the laser ablation procedure.Fluoroscopic guidance during procedures in the anteroposterior and lateral projection was essential to ensure a precise skin entry point. Anesthesia was limited to 1% local lidocaine 7–10 cc with epinephrine mixed with 1.6% lidocaine 2-3 cc, 3–5 minutes after the 1st injection. In the provocation steps, the main painful point was commonly located in the upper endplate of the lower vertebral body. The needle was inserted into the suprapedicular notch  to get at-test to evaluate the significant difference in the preoperative and postoperative clinical outcome parameter, that is, VAS score. The significance level was considered at 0.05. The statistical software used for the study was SPSS version 20.0 .The clinical outcomes were evaluated using descriptive statistical analysis. We conducted Student's paired P < 0.0001 (P < 0.0001) and 2.36 ± 1.01 , respectively  years. There were six men and eight women; in all patients, MRI findings correlated with clinical findings. The mean symptoms duration was 21.21 ± 21.87 (range: 4–84) months. The mean follow-up was 15.3 ± 2.67 months (range: 12–20 months). Pfirmann's disc degeneration grade was grade IV in 8 (57.14%) patients and grade V in 6 (42.85%) patients. Eight and six patients had Modic type 1 and type 2 changes, respectively . The pre< 0.0001 . Signifiectively . As per ectively .There were no occurrences of infections, discitis, paresis, dural tears, vascular injuries, or systemic complications until the latest follow-up. Furthermore, the patient's VAS scores for back pain and Macnab's criteria were maintained at the final follow-up compared with postoperative scores. All patients maintained their functional neurologic status throughout the entire study follow-up. There were no device- or procedure-related serious adverse events in this study.The Modic change caused by disc degenerative processes involving damage and microfractures to the vertebral endplates results in the development of edema and inflammation of the adjacent vertebrae , 11. FacModic change is associated with chronic back pain . While pA study by Becker and coworkers reported that the primary innervation for the vertebral body is by the BVN that enters the bone of the vertebral body via the midline of the posterior cortex. The large, usually paired, neurovascular foramina are located equidistant from each endplate. These nerves accompany the basivertebral artery and vein  Figure . PreviouBasivertebral nerve sensitization causes CLBP. Substance P, a peptide neurotransmitter of the tachykinin family, is found within the basivertebral nerve, and there is very strong evidence that this nerve has the potential for transmitting pain signals , 18–20. 5P < 0.0001). This result is encouraging and the procedure was safe.The major limitation of this study is the lack of a comparative control group. Similar to any other retrospective studies, limitations associated with our study include retrospective clinical outcome assessments and small sample size since very few patients actually require surgical intervention. Nevertheless, after TEBLA, we got 93% good-to-excellent results according to Macnab's criteria, and the preoperative VAS score of 7.79 ± 0.97 decreased to 1.92 ± 1.38 at the latest follow-up (The TEBLA appears to be a promising option in carefully selected patients with chronic low back pain associated with the Modic changes. The treatment improved patients' self-reported outcomes, and the improvement was largely maintained through more than 12 months of the follow-up period.


The study objective was to assess the quality of life and satisfaction with treatment of patients with chronic neuropathic pain (CNP) who experience breakthrough pain (BTP) and to assess its economic impact. Cross-sectional observational study. Fifteen pain units from Spanish hospitals completed the study. A total of 124 patients with adequately controlled CNP who experienced BTP were enrolled into the study. No interventions were required. Quality of life was assessed using the SF12 v2 questionnaire, the results of which were used to calculate the estimated costs per patient and month and the SF-6D Health Utility Index. Patient satisfaction with treatment received for CNP and for BTP was assessed using a 10-point visual analogue scale. Other associated symptoms were analyzed using the ESAS (Edmonton Symptom Assessment System). Patients had a mean age of 60.2 years (95% CI 58.4-63.3), and 46.8% (58) were males. 18.9% (23) experienced their first episode of BTP. A severe impairment of the physical component of SF12v2 was noted, with 94% of patients below the mean score of the population, while 88% had values lower than normal for the mental component. Mean cost per patient and month was $679 and was significantly greater in males ($763 versus $606), 4.96 times greater than in healthy population, and approximately double the cost of patients with CNP in Spain. Occurrence of BTP in patients with CNP causes a substantial increase in healthcare costs which is significantly greater in older males. The International Association for the Study of Pain (IASP) defines neuropathic pain as pain initiated or caused by a primary lesion or dysfunction of the peripheral or central nervous system. Such lesions include a large number of neurological conditions including diabetic polyneuropathy and other sensory neuropathies, trigeminal neuralgia, postherpetic neuralgia, stroke, spinal cord lesions, and multiple sclerosis, as well as other more common conditions such as lumbar and cervical radiculopathies and traumatic or postoperative injuries –4 NeuropA high proportion of patients with neuropathic pain experience breakthrough pain (BTP) at some time during the course of their condition. BTP is defined as a “transient exacerbation of pain that occurs either spontaneously or in relation to a specific predictable or unpredictable trigger, despite relatively stable and adequately controlled background pain” . IncidenOccurrence of BTP has a very significant impact on the quality of life of patients and is also characterized by being associated with a high use of healthcare resources , 16. PatThe quality of life impairment experienced by patients with neuropathic pain who also suffer BTP, the medical costs in such patients, and their degree of satisfaction with treatment they receive for the two types of pain are currently unknown and were the primary objectives of the study.A retrospective observational study was designed. The ethics committee of Hospital Universitario La Paz in Madrid (Spain) approved the study (17 March 2016). The basic ethical principles of the Declaration of Helsinki were respected in the study.Fifteen pain units from 13 Spanish provinces participated, enrolling patients from June to December 2016.Patients of both sexes over 18 years of age with history of neuropathic pain, adequately controlled at the time of selection, as shown by a score of four points or less in a 10-point visual analogue scale of pain intensity, this being the maximum pain value, were enrolled. Background pain was considered neuropathic in nature if the score in the DN4 questionnaire (Dolour Neuropathique 4 questions) was four points or greater , 20. PatAll patients were given written information about the study and its objectives and signed an informed consent before study entry.Patients were consecutively selected among the patients who attended the outpatient clinics of pain units. No specific treatment was required to be included in the study.The primary objective, assessment of quality of life of patients, was evaluated with the SF-12 questionnaire at the time of the visit. The SF-12 questionnaire is a short version of the SF-36 Health Survey. It is a self-administered questionnaire that measures health-related quality of life from the patient perspective and is completed in approximately two minutes. SF-12 collects 12 questions to the patient in Likert scales of 3 to 5 responses. The SF-12 has two components, physical component (PC) and a mental component (MC) with the following dimensions: physical component: PF: Physical Functioning; RP: Role Physical; BP: Bodily Pain; GH: General Health; and mental component: VT: Vitality; SF: Social Functioning; RE: Role Emotional; MH: Mental Health .The results of the SF-12 questionnaire allowed the calculation of estimated costs per patient and month, evaluation of costs by age group and sex, and comparison of such costs to those for a healthy patient of the same age group and sex . The scoThe SF-6D is a health index derived from the SF-12 v2 for use in economic evaluation studies. Seven of the eight domains of SF-12 v2 were used to calculate SF-6D. The score ranges from 0.0  and 1.0 . Medical expenditure is calculated using a regression equation that considers health-related quality of life data, sex, and age. The algorithm to calculate medical costs is validated and uses data from the Medical Expenditure Panel Survey, a representative national survey on use of healthcare resources and expenditure in noninstitutionalized US population . SpecifiPatient satisfaction with treatment received for background pain and BTP at the time of the visit was assessed using a 0-10-point visual analogue scale (VAS), where 0 represented “Not at all satisfied” and 10 “Very satisfied”.As a secondary objective, an analysis was made of control of symptoms associated with the disease, assessed using visual analogue scales  that rated pain, tiredness, nausea, depression, anxiety, drowsiness, anorexia, discomfort, dyspnea at rest, and insomnia in the past 24 hours . SymptomInformation was collected on age, sex, and socioeconomic status , on patient weight and height, and on disease history. The characteristics of background pain, the DN4 score, characteristics of the BTP listed in The primary study variable was assessment of quality of life using the SF-12 questionnaire at the time of the visit and comparison of the scores to population standards. The normal value of the physical component of the SF-12 questionnaire for subjects aged 55-64 years in Spain is estimated to be 46.97 points, with a standard deviation of 10.21 . AssuminA descriptive analysis was performed of study variables. Frequencies and percentages were calculated for qualitative variables, and mean, standard deviation, 95% confidence intervals, and minimum and maximum were calculated for continuous variables.Comparisons between qualitative variables were made using a Fisher test or a Chi-squared test. Student's t-test was used to compare independent groups in the case of quantitative variables.When differences in quality of life and costs were assessed using different control variables, the factorial model of analysis of variance was used, applying Bonferroni or Games-Howell correction depending on homogeneity of variance, to control error for multiple comparisons. For analysis of the SF-12 questionnaire, specific software from questionnaire owners was used . SignifiA total of 124 patients who met all selection criteria were enrolled into the study. Of these, 53.2% (66) were females and 46.8% (58) were males, with a mean age of 60.8 years (95% CI 58.4-63.3), a median age of 60 years, and ages ranging from 34 and 85 years. Females were significantly older (p=0.016), with a difference of 5.9 years (95% CI 1.1-10.7).2 (95% CI 25.4-27), with no differences between males and females (p=0.285).Of all subjects, 68.5% (85) had a middle socioeconomic status, 22.6% (28) a low status, and 8.9% (11) a high socioeconomic status. Mean body mass index was 26.2 kg/mHistory of oncological disease was found in 37.1% of study patients (46). Gastrointestinal tumors were most common , followed by lung , breast , prostate , and other tumors . Mean time from tumor diagnosis to the study visit was 2.7 years (95% CI 2-3.4), with a median of two years .The main cause of chronic pain was spine problems , followed by tumors  and peripheral neuropathy .Mean score in the DN4 scale for assessment of neuropathic pain was 6.1 (95% CI 5.8-6.5), with a median of 6 points.Patients had the first episode of BTP in 18.9% (23) of the cases and were on follow-up of the remaining 81.1% (99) with 2 missing data.A single active ingredient was administered to 112 patients (90.3%) to treat BTP, while seven patients (5.7%) received no active ingredients and five patients (4%) were administered two active ingredients. All SF-12 v2 items were completed by 97.7% of patients, with 100% validity for convergence and discriminant analysis. Calculations of the physical and mental components were obtained from the data of 122 of the 124 patients enrolled. general health dimension were statistically significant (p=0.044), with 2.8 points less in females (95% CI 0.1-5.6). Scores in the mental health dimension were also lower in females, with differences of 3.1 points (95% CI 0.3-5.8), p=0.028. A univariate analysis found no significant differences in the components and dimensions of the SF-12 v2 questionnaire by sex, between patients with and without tumors, by socioeconomic status, or depending on whether the patient had experienced the first episode of BTP or was on follow-up.In the multivariate analysis including data of 120 patients, where the scores of the physical or mental component of the SF-12 v2 questionnaire were the dependent variable, the independent variables, sex, age, socioeconomic status, patient with BTP de novo or under follow-up, and patient with and without tumor, resulting were not statistically significant.In the physical component, 94% of patients in the study were below the mean score of the population, 5% within the normal range, and 1% above normal values. In the mental component, 88% were below the normal levels of the general population, 11% were within normal values, and 1% were above normal values. There was a greater proportion of males with physical component scores below normal values (98% versus 91%) and a greater proportion of females with mental component scores below normal values (89% versus 86%).Seventy-two percent of patients enrolled into the study were at risk of depression, with a greater proportion of females (80% versus 64%), p<0.05. statistically significant differences in medical expenditure between males and females (p=0.006), with a cost $157.5 greater in males (95% CI 46.5-268.5). In Mean monthly cost of each patient participating in the study was $679.24 (95% CI 622.3-736.2), resulting in females of $605.7 (95% CI 553.7-657.6) and in males of $763.2 (95% CI 658.9-867.4). There wereThe overall study sample had a score of 0.51 (95% CI 0.50-0.53) in the Health Utility Index.Univariate analysis showed no statistically significant differences in medical expenditure or the utility index between patients with and without tumors, between patients with BTP de novo or on follow-up, or by socioeconomic status and age. No sex differences were seen in the utility index.In the multivariate analysis including data of 120 patients, including the control variables listed in the previous paragraph, no significant relationship was seen with the utility index, but patient sex and age were found to be statistically significant for monthly medical expenditure . Costs were significantly greater in males  and are greater if the patient is older . Age/sex interaction was statistically significant (p<0.0001). Costs were greater in females until 49 years of age and in males after that age.Ninety-six patients (77.4%) were satisfied with treatment for chronic pain, 66.4% (81 patients) were satisfied with treatment for BTP, and 56.6% (69 patients) were satisfied with both treatments.Patients with neuropathic pain are a group who attend pain units very often. The frequency with which these patients experience BTP is also high. Assessment of the quality of life of study patients with background neuropathic pain and BTP showed a severe impairment of the physical component of the SF-12 v2 quality of life questionnaire and a great proportion of patients with quality of life values lower than normal standard in both the physical component (94%) and the mental component (88%). The SF-12 v2 questionnaire also revealed that 72% of patients were at risk of depression, as compared to 20% of the general population . No relaMean healthcare cost calculated based on the SF-12 v2 questionnaire was $679, but cost was significantly greater in males and the older the age. As compared to the mean healthcare cost in the healthy US population of $137, in this study, with patients with CNP associated with BTP, medical expenditure was 396% higher than in the normal population that is 4.96 times greater than in the healthy population. Monthly cost per patient with neuropathic pain in Spain has been estimated at approximately €363, which is about half the cost seen in the study where the patient has both neuropathic pain and BTP . This diOpioids have been reported to be the main relief factor in BTP episodes in 44.61% of patients, while 26%-44% find relief avoiding the movement that causes pain, and 12%-20% do not appear to achieve adequate relief with drug and nondrug measures . BecauseThe study assessed the degree of patient satisfaction with treatment received for CNP and BTP. Treatment satisfaction was reported 77.4% of patients with CNP and by 66.4% of patients with BTP. Single drug treatment was given to 90.3% of patients being fentanyl the most commonly used active ingredient: 70.9% (61 patients) using the nasal spray administration, 23.3% (20) sublingual, and 5.8% (5) the inhaled route. The lower degree of satisfaction with treatment for BTP may be related to the greater difficulty of such treatment in this group of patients, secondary to the greater difficulty in treatment of CNP, since the characteristics of BTP were similar to those reported in other studies .The cross-sectional design of the study was adequate to assess the study objectives, with the limitations inherent to studies of a descriptive nature. The small number of missing data allowed for exploratory inferential analysis in 120 of the 124 patients.The study conclusion is that occurrence of BTP in patients with CNP causes a substantial increase in healthcare costs which is significantly greater in older males.


Clinical Study: Pregabalin Effect on Acute and Chronic Pain after Cardiac Surgery” by Bouzia et al. [We have read with great interest the article entitled “a et al. . We apprFirst, it is not mentioned when exactly the patients received the single dose of the “study drug” and if there was any delay in the extubation time. In other studies, the results were unstable as time to extubation was significantly longer in the pregabalin group , 3 or siThe visual analogue scale (VAS) and numeric rate scale (NRS) are equally sensitive in assessing acute pain after surgery, and they are both superior to VRS, but the authors chose to use the verbal rating scale (VRS) for assessment of pain intensity, although they finally describe the numeric rate scale. It is remarkable that VRS can be converted to numeric scores for charting and easy comparison, but the authors did not mention or explain this option.We think that the whole plan of postoperative analgesia has many limitations. First, it is not clear when the patients received the initial dose of morphine (5 mg). Also, they preferred to use a background infusion with the programmable PCA pump and a too long lockout interval combined with a bolus dose of 0.5 mg morphine. Additionally, they provided rescue analgesia with IV morphine if the above scheme with the pump was not sufficient.It is well known that chronic pain after cardiac surgery is multifactorial and according to the authors with only one dose of pregabalin the patients in the pregabalin groups experienced less severe postoperative pain, used less analgesics, and reported less sleep disturbances without explaining which pain assessment tools they used and if the assessment was done at rest or at stress. Also, it is remarkable that many patients after cardiac surgery may have neuropathic pain characteristics, and it is appropriate to use not only chronic pain assessment tools but also neuropathic pain screening tools such as DN4 .In our opinion, all these limitations may be responsible for their results. More studies and especially well-designed clinical trials are required in order to clarify the optimal dose, the duration of therapy, and the benefits and risks before adopting pregabalin in routine clinical practice and especially in patients undergoing cardiac surgery. Until then, the results may not be as ideal and promising as it sounds.


In patients with focal nerve injury and neuropathic pain cutting the nerve to obtain permanent pain reduction can be considered. Surgery is indicated only if a diagnostic nerve block provides temporary pain relief. We evaluated the predictive value of a block on the outcome of surgery.In total, three blocks were performed at two week intervals. Patients were blinded to injections containing lidocaine 1% and a placebo was included. Surgery was offered regardless of the effect of the blocks. Twenty-four patients received 72 blocks. Sixteen patients opted for surgery, 5 patients refrained from surgery, and in 3 the blocks provided permanent pain relief. The predictive ability of the block on the outcome of surgery was assessed by calculating the area under a Receiver Operating Characteristic curve (AUC).The AUC of the first lidocaine block was 0.35 with a 95% confidence interval from 0.077 to 0.62. At 95% confidence (two-sided), the AUC is less than 0.62, and hence the predictive ability of the block was poor. The outcome of the second lidocaine block and saline block did not change the conclusion of the first block.We conclude that the use of blocks to select patients for surgery should be critically appraised.A pain relieving response to one open block is currently considered mandatory before patients with focal nerve injury and neuropathic pain are offered surgery. Blinded blocks including a placebo show that responses for selection should be carefully interpreted because they may not be as predictive as generally presumed. The neurnsations. Neuropatnsations.,4 Alternnsations.Surgical treatment of the damaged nerve is considered as an option when all other treatments have failed. The surgical technique consists of either neurolysis and releasing the nerve from the scarred area or neuroma resection with relocation and burying of the proximal stump. The nervWe used a different protocol in our patients. The protocol is applied exclusively to patients with probable neuropathic pain due to nerve injury and who We looked for the level of evidence for the use of a block for selection  by assesA standardized diagnostic nerve block protocol was applied in the work-up of patients in whom nerve surgery to treat neuropathic pain was considered. All of tPatients were operated under general anaesthesia. The nerve trunk proximal to the area of maximal pain was dissected free and dissection continued distally into the zone of tissue and nerve damage. The responsible nerve branch ending was identified and cut just proximally to the neuroma into healthy looking nerve. Skin branches leaving the nerve trunk proximal to the neuroma and which were not involved in the lesion were left intact. The neuroma of the damaged nerve was resected. The proximal nerve stump was loosely buried as deep as possible away from potential sites of mechanical pressure and joints. The stump was enveloped by fat tissue and secured with a 5.0 vicryl suture. Finally, wound closure was performed according to standard procedures. The effect of surgery on pain was documented using five point scale: 0 = no effect, 1 = partial pain reduction, 2 = (as good as) pain free, 3 = temporary pain reduction, 4 = increase of pain as compared to the pre-operative level.To assess whether the response to the nerve block is predictive of the success of the surgery, we proceeded as follows. The result of the block was ordered according to a (presumed) increasing likelihood of a successful surgery: a) no effect; b) increase of pain for hours or days; c) pain relief for days; d) pain relief for several hours. The outcome of surgery was dichotomized as unsuccessful  or as successful  pain free following surgery). A decision rule for recommending surgery would involve a cut-point for the result of the block. For instance, one might recommend surgery to patients who score better than b) on the block. Such a decision rule will result in two types of errors: recommending surgery to some patients who do not benefit, and not recommending surgery to patient who do benefit. Changing the cut-point will impact the probabilities of both types of errors. Plotting the sensitivity versus 1-specificity of the decision rule for varying cut-points yields a so-called Receiver Operating Curve (ROC). The area under this ROC cure (AUC) is a commonly used measure of predictive ability. The AUC is expressed between 0 and 1. The predictive ability and accuracy of a diagnostic block is excellent if the AUC is between 0.90–1.0. The test is good with an AUC between 0.80–0.90, fair between 0.70–0.80, poor between 0.60–0.70, and failed if the AUC is between 0.50–0.60. An AUC less than 0.5 is worse than random guessing.;64 We usBetween 2008 and 2013, a total of 24 patients  met the inclusion criteria.  The meanThe pain started after a surgical intervention in 18/24 of the patients (75%), of which the pain developed immediately following surgery in 13/16 (80%), and in 3/16 (20%) of the patients after weeks to months. In 6/24 (25%) of patients, the pain started following a trauma; in 3 immediately following trauma, and in the other 3 patients weeks to months later.The different effects of the blocks on pain are shown in In 26 of the 48 lidocaine blocks (54%) a pain reducing effect was observed. The effect of the second lidocaine block was similar to the first in 16/24 (66%). Pain reduction following both lidocaine blocks was found in 10/24 (42%) of the patients.A pain relieving effect of the first lidocaine block was obtained in 16/24 (66%) of the patients, which lasted for several hours in 7/24 (29%) and for many days in 9/24 (38%). There was no effect of the first lidocaine block in 7/24 (29%) of the patients. One patient of the 24 (4%) observed more pain following the first lidocaine block and 5/24 (21%) after the second lidocaine block. In total, 16/24 (66%) of the patients had strong pain reduction in at least one of the two lidocaine blocks regardless of the duration of the effect.A pain relieving effect of placebo lasting for days was noted in 7/24 (29%) of the blocks. No effect on pain following saline injection was noted in 9/24 (38%) of patients. A temporary increase of pain following saline injection was seen in 8/24 (33%).No permanent adverse effects of the injections were seen. In 3 of the 24 patients, the injections induced a continuous pain relieving effect to such an extent that these patients did not need surgery nor did they require further pain treatment. Five of the remaining 21 patients who were offered surgery refrained. They requested a 100% guarantee to get significant pain relief following surgery which could not be given, or nerve surgery was judged to be too radical.Sixteen of the 21 patients opted for surgery. The mean interval between the nerve lesion and the operation for pain was 38 months . The mean interval between the first block and the operation was 6 months . The mean follow-up after the operation was 15 months .At surgery, the nerve was cut and buried in fat. A permanThe AUC of the first lidocaine block was 0.35 with a 95% confidence interval (CI) from 0.077 to 0.62. We conclThe AUC of the second lidocaine block was 0.63   Fig 1) OThree technical factors potentially affect the outcome of our analysis: the blocking procedure, the surgery and the blinding. First, we may actually not have injected lidocaine in the close surroundings of the involved nerve. This would then erroneously lead to false negative blocks. Our blocks were performed following current routine. We injected 4 cc. of lidocaine to reduce the chance of lidocaine not reaching the nerve. Usually, a volume of 1–2 cc. is used.,39,50,66Second, there is no consensus as to which envelopment of the proximal stump is optimal.  The proxThird, in routine practice  patientsThe low accuracy of blocks to predict the effect of surgery probably reflects the multifactorial complex nature and origin of neuropathic pain. Following the nerve injury, the axonopathy and demyelination trigger membrane remodelling in injured afferents and in uninjured neighbours supplying the affected region. Subsequently, cellular excitability increases in part due to sodium (Na+)- channel dysfunction. This leads to ectopic generation of action potentials constituting a primary neuropathic pain signal. LidocainGenerally, the duration of the pain relieving effect of infiltration with 1% lidocaine is two to six hours. In our sThe varying effect of lidocaine in terms of the duration and intensity indicate that not only Na+- channel dysfunction is at play. Multiple different sites for pain along the neural axis are involved. Central Lidocaine is used in the vast majority of the blocks.,60,61,66Pain reduction can be achieved with nerve surgery, but to what extent and in which percentage of the patients cannot be summarized from the literature because of the different ways of reporting. In this series, 44% of the patients had good pain relief. Traumatic neuromas show spontaneous discharge activity and ectopic sensitivity to mechanical stimuli. It mightImmediate surgical repair of the damaged nerve would be optimal, but usually requires a graft. This would then imply sacrificing an intact cutaneous nerve, most often the sural nerve, in order to restore the damaged one. This trade-off is generally considered not favourable enough to justify grafting. Whether biodegradable nerve tubes or cadavThe strength of our study is that we only included patients who met the criteria for persistent postsurgical or nerve injury induced probable neuropathic pain. AdditionWe recognize several weaknesses in this study. Ideally, a prospective randomized double blinded set-up would be best. Furthermore, a relative small group of patients was surgically treated. The predictive ability of the block, however, was so low that the possibility that it would be improved by the inclusion of a larger number of patients is small. In our study, 16 different anatomical nerves were damaged, all to a different extent. The penetration of lidocaine might have been influenced by the relative contribution of supportive tissue, the fiber composition, number of fibers and fascicles and fascicular pattern which varies between nerves and individuals. Also, thOffering surgery to patients with focal nerve injury and neuropathic pain only if a pain relieving response to one open block is obtained is probably not a good method. Open blocks may not be as predictive as generally presumed. The selection algorithm needs to be critically re-evaluated.S1 Minimal Data Set(DOCX)Click here for additional data file.


Lumbar spinal stenosis most often results from a gradual, degenerative ageing process. Open or wide decompressive laminectomy was formerly the standard treatment. However, in recent years, a growing tendency towards less invasive decompressive procedures has emerged. The purpose of this study was to compare the results of microdecompression with those of open wide laminectomy and posterior stabilization for patients with symptomatic multilevel lumbar spinal stenosis who failed to respond to conservative treatment.  This randomized controlled study was conducted between January 2016 and October 2018. One hundred patients were involved in this study. All these patients suffered from radicular leg pain with MRI features of multilevel lumbar spinal stenosis and were treated by conservative treatment of medical treatment and physiotherapy without benefit for 6 months. Those patients were divided into two groups: Group A, 50 microdecompression, and Group B, 50 patients who were treated by open wide laminectomy and posterior stabilization. Both groups of patients were followed up with ODI (Oswestry disability index) and VAS  for the back and leg pain for one year.  The results showed that both groups got significant improvement regarding the Oswestry disability index. Regarding back pain, there was a significant improvement in both groups with better results in group A due to minimal tissue injury as the advantage of the minimal invasive technique. In both groups, there was marked improvement of radicular leg pain postoperatively. NCT04087694. Both microdecompression and wide open laminectomy with posterior stabilization were effective in treatment of multilevel lumbar spinal stenosis with superior results of microdecompression regarding less back pain postoperatively with less blood loss and soft tissue dissection. Clinical trial number:  Stenosis of the lumbar spine is an extremely widespread disorder that frequently arises from a gradual degenerative ageing progression . The cliThe present study aimed to compare the results of microdecompression for multilevel lumbar spine stenosis with those of open laminectomy and posterior stabilization regarding the Oswestry disability index and visual analogue score for back pain and leg pain.The protocol of this study was reviewed and approved by the research ethics committee in our university. Written informed consents were obtained from all patients. This study is a randomized controlled trial. One hundred patients were involved in this study from January 2016 to October 2018. All these patients suffered from back pain of different degrees with spinal claudication and were treated by conservative treatment of medical treatment and physiotherapy without benefit for 6 months at least. MRI of the lumbosacral spine showed multilevel spinal stenosis L3-S1, and all patients were assessed clinically and radiologically. All patients underwent dynamic flexion and extension lumbosacral plain x-ray to exclude any instability.The patients were divided into two groups according to the ODD and EVEN number on receiving of the patients: Group A, 50 patients who were treated by microdecompression, and Group B, 50 patients who were treated by open laminectomy and posterior stabilization with pedicle screws from L3 to S1 levels.The two groups of patients were operated by one team which consisted of one orthopaedic surgeon and one neurosurgeon. The instability was assessed by dynamic X-ray, and those cases with instability were excluded. Cases with decreased disc height and disc degeneration of significant degrees were not involved in this study. All patients in this study suffered from radiculopathy as the primary complain, and those cases with only back pain (discogenic pain) are not involved in this study.All these patients were assessed and followed up by ODI preoperatively and 1 month postoperatively and VAS for back pain and leg pain preoperatively, in addition to 1, 6, and 12 months postoperatively.Exclusion criteria of the present study include smoking, diabetic patients, previous spinal surgery, any neuromuscular disorder like poliomyelitis, vertebral instability proved by dynamic plain radiographs, and patients with significant loss of disc height and degeneration.t-test was used to compare means between two groups. The Mann–Whitney U test was used to compare two groups when the variable was not normally distributed. The paired t-test was used to compare means for paired reading. The Pearson's chi-square test (χ2) was used to find the association between categorical variables. A P value of ≤0.05 was considered as significant.Statistical analysis was carried out using SPSS version 21 for Windows . Categorical variables were presented as frequencies and percentages. Continuous variables were presented as Mean ± SD. The student's Under general anesthesia, with supine position and flexion of both hips and knees by pillows, and with the aid of a microscope, midline incision was done after determination of the spinal levels by fluoroscopy with cautery. The deep fascia was opened, and paravertebral muscles were retracted laterally to expose the lamina of L5 on the symptomatic side. Then, by high speed drill the lamina was thinned by passing a hook under the lamina and retracting the ligamentum flavum; then, by using tenotome the ligamentum falvum was incised over the hook; then, by karyson the ligamentum flavum was removed to expose the dura and the nerve root on that side; foraminotomy was performed; and then, the microscope was tilted 15 degrees, and the bed of the patient was tilted 15 degrees. Therefore, we directed the microscope on the contralateral side to remove a part of the lamina and the ligementum flavum to decompress the contralateral nerve root; then, hemostasis was performed starting with proximal level (L4) and then (L3) with the same technique but on the alternating way. After securing hemostasis, the surgical wound was closed in layers with no drain. The patients are mobilized after 6–8 hours after operation.Under general anesthesia, with supine position and flexion of both hips and knees by pillows, midline incision was performed after determination of the target levels from L3 to S1. By cautery, the deep fascia was opened, and the paravertebral muscles were retracted to expose the laminae from L3 to L5. Insertion of pedicle screws from L3 to S1 (the stenosed levels) and wide laminectomy were performed to the stenosed levels with decompression of the nerve roots and then hemostasis secured. The rodes were inserted with consideration of lumbosacral lordosis; decortication was performed, and the bone grafts were put posterolaterally from the removed spinous processes and laminae. The surgical wound was closed in layers with drain which was removed the next day, and the patient started mobilization the next day postoperatively.P=0.001∗), while there were nonsignificant differences between two groups after six and twelve months of operation (P=0.421 and P=0.57).P < 0.001∗, P < 0.001∗), while there were no significant differences between means of VAS for back pain between these two groups after 12 months (P=0.524).P=0.618, P=0.604, and P=0.23, respectively).In our study, we found that both groups got significant improvement regarding the Oswestry disability index . RegardiThis result was reliable using various policies for analyzing data. A possible clarification is that microdecompression decreases surgical trauma, permitting early mobiliation after surgery. Nevertheless, it is also probable that surgical units adapting to least invasive procedures will be prone towards shorter hospital stays, taking different practices for postoperative mobilization, pain management, and hospital discharge. Conventional laminectomy with removal of posterior bony and ligamentous structures has been the gold standard of surgical treatment for decades. Although postoperative development of segmental instability is a multifactorial problem, unnecessary damage to anatomic structures, which stabilize the functional spinal unit, has always been a problem with this technique –11. MoreAll cases in group A (who underwent microdecompression) had no instability as instability was considered as an exclusion criterion .Both microdecompression and open laminectomy with posterior stabilization were effective treatment methods for lumbar spinal stenosis regarding leg pain with less postoperative back pain in the group of microdecompression with less operative time, less blood loss, and less cost.


Patellofemoral pain syndrome (PFPS) is a common musculoskeletal disorder. There is little consensus on the etiology, but one explanatory model suggests that PFPS can be caused by referred pain. Neurodynamic tests are used to explore the mechanosensitivity of peripheral nerves, and previous studies have shown a relationship between increased mechanosensitivity and anterior knee pain by using the femoral slump test (FST). Previously the prone knee bend test (PKB) does not appear to have been included. The main purpose of this pilot study was to examine whether there was an identifiable difference in mechanosensitivity between left and right sides that could be identified using both the PKB and FST tests for the femoral nerve in patients with unilateral PFPS.This cross-sectional pilot study tested 12 patients with unilateral PFPS for altered mechanosensitivity using both PKB and FST. The pain-free knee was used as a control. The selected test procedures were similar to those clinicians use in everyday practice.p < 0.05 Wilcoxon Signed Rank Test). The symptoms were more often located in the anterior knee, with structural differentiation by neck flexion appearing to increase the symptoms more when testing the leg with PFPS.8 and 4 of the 12 patients were found to have increased levels of mechanosensitivity in the PFPS leg using the PKB and FST, respectively. Both tests provoked stronger pain in the leg with PFPS compared with the asymptomatic leg (Although the reliability of the tests is unknown and the study sample size was small, the PKB and FST test procedures used in clinical practice appear capable of revealing altered mechanosensitivity in unilateral PFPS patients. The PKB test appears to detect mechanosensitivity in more patients than the FST. We recommend including both tests in future larger blinded controlled studies which should also assess reliability of the tests.ISRCTN 12473526. Registered 20 May 2015, retrospectively registered. Anterior knee pain from patellofemoral pain syndrome (PFPS) is a common musculoskeletal disorder. The main symptom is pain during activity, although there are large variations in the type and level. PFPS tends to affect active young people and can become a long-lasting health issue that prevents patients from living an active life . There iSeveral studies have provided new insight into PFPS and support that neurogenic dysfunctions might be involved , 11–13. Several clinicians seem to have changed their thinking about PFPS from being a pure “local” mechanical problem to being more the result of sensitization in the nervous system. Due to courses and textbooks on the topic, several therapists have also implemented neurodynamic- tests and treatment for musculoskeletal conditions in both the upper and lower extremities. The purpose of using neurodynamic tests has been to explore the nervous tissue’s ability to tolerate mechanical force and traction. If the test reveals increased mechanosensitivity , it is interpreted as neurogenic dysfunction , 17, 18.Neuorodynamic tests are intended to move neural structures and mechanically apply tension to them. This tension is supposed to arouse a normal positive response that evokes neurogenic symptoms . If the Various studies have explored the association between conditions in the lower extremities and dysfunctions of the femoral nerve , 23, 24.There seems to be a lack of consensus on how to perform and interpret the different neurodynamic tests, as well as how to standardize and grade mechanosensitivity. Furthermore, there are different definitions of a positive test. However, there seems to be agreement that increased mechanosensitivity should be evaluated in each test individually and that the responses should be compared with the contralateral side , 24, 25.The main purpose of this pilot study was to examine whether a side difference in mechanosensitivity could be identified using both the PKB and the FST tests for the femoral nerve in patients with unilateral PFPS and to use the patient’s asymptomatic leg as control. The selected test procedures are similar to what clinicians use in everyday practice. We hypothesized that the responses would be different in the two legs, that there would be a smaller range of motion (ROM) at the onset of the pain/discomfort, stronger pain at the end of the ROM, and that the participants’ anterior knee pain could be reproduced in the PFPS leg. We also hypothesized that there would be a positive structural differentiation in the affected leg, assessed in the FST.The participants in this cross-sectional pilot study were 12 patients with unilateral PFPS who were between 18 and 44 years old. All were recruited from a physiotherapy clinic in primary health care and can be seen as a convenience sample. We identified relevant patients from the clinic’s waiting list, contacted them by telephone, and asked them about participation. An interview and a clinical examination were used to confirm the diagnosis and fulfillment of the inclusion criteria.The inclusion criteria were: 1) a history of unilateral anterior knee pain located around the patella and lasting for more than 3 months, 2) the ability to participate in normal daily activities, 3) pain at rest, during daily activities , or when performing sports or exercise activities, and 4) no symptoms in the other leg, which was used as an asymptomatic control. Patients with known intra-articular disorders, previous surgery or trauma in the legs, or a knee injection during the last 3 months were excluded from participation. During the inclusion process, two patients were excluded: one because of trauma and one with a neurological diagnosis. The Regional Committee for Medical and Health Research Ethics approved the study (2010/819–4).A pain drawing was used to identify the location of pain, confirm the knee pain, and explore the presence of pain in other areas of the body. Pain intensity over the last 2 weeks was examined by a Visual Analogue Scale . The Norwegian version of the modified Cincinnati Knee Rating System questionnaire (CRS) was used to obtain information about pain and function. The self-administered CRS contains 12 questions about knee pain, swelling, and function, and a sum score is made . The CRS outcome is evaluated as poor (< 30), fair (30–54), good (55–79), or excellent (> 80). We also calculated two CRS subscores for pain and activity. The maximum in each subscore was 20 points (the best score). The CRS has previously been validated in patients with chronic knee pain , 27.. Studies have also reported significant lower mean step rates in the affected legs of patients with unilateral pain [To evaluate the participants’ function, we used a test including both weight bearing and knee bending since these activities commonly aggravate the pain in PFPS patients. Loudon et al. found the step down test to be the most sensitive and reliable test out of five different performance-based tests. Furthermore, they found it to be the only test to discriminate between PFPS patients and controls and reported 100% symmetry between the legs in people with no knee pain . Studiesral pain , 28.We explored whether the test revealed asymmetry between the affected and unaffected leg. The participants performed single leg squats from a 20-cm-high step. They were instructed to go deep enough for the heel on the other leg to touch the floor and then to return to the starting position Fig. . The numWe used the PKB and FST to examine the mechanosensitivity of the femoral nerve. The PKB tested the femoral nerve in a prone position Fig. , and theTo obtain all measurements as positive numbers, we measured the hip-extension ROM in the FST using a different method. We started measuring extension from 90 degrees of hip flexion . From this position, hip extension was passively performed until the patient reported pain or discomfort. At this point, we recorded the ROM in degrees. For example, if the patient were able to extend their hip to zero degrees of extension, the measurement would be noted as 90 degrees.The level of pain was scored with a numeric pain rating scale . Each participant was tested twice with a break of 45 min in between. The average of the responses in each leg (ROM and NPRS) in the two examinations was used in the analyses  and symptom areas not involving the knee (scored as 0).The ROM when pain or discomfort was first perceived was measured by a universal goniometer, and the results were compared between the affected and control legs. Various standard errors of measurement have been reported for the universal goniometer (0.52–2.66 degrees in knee flexion and 2.8–3.5 degrees in hip extension). We used a cut-off difference of 3 degrees for the PKB and 4 degrees for the FST , 31. MeaAt the end of the ROM, we compared the pain intensity (NPRS) registered in the affected and the asymptomatic control legs. There is an international consensus that the minimal important change (MIC) on the NPRS in chronic pain patients should be more than 30%. Furthermore, a change of 2 units is defined as “much better,” while a change of 1 unit is “slightly better” . A diffeNeck flexion was performed in conjunction with the FST to explore possible changes in pain or discomfort. Structural differentiation where neck flexion increases distal pain or discomfort is generally interpreted as a neurogenic symptom –10. We rAll components were scored and recorded for both neurodynamic tests, and side-by-side comparison was used to determine whether mechanosensitivity was increased. We decided whether a high level of increased mechanosensitivty was present in the affected leg by using a sum score of all three components for the PKB and all four components for the FST for each patient. Furthermore, we defined a maximum sum score of 3 on the PKB and 4/3 on the FST as a high level of increased mechanosensitivity.p < 0.05.All analyses were performed using SPSS version 18 . Background data, pain areas, and structural differentiation are presented as frequencies. Pain and function scores are presented with the mean, range, and standard deviations (SD). On the neurodynamic tests, the ROM and pain responses are given as the median and range since the data were skewed. The differences between the affected leg and control legs were tested using the Wilcoxon Signed rank test for continuous variables (NPRS and ROM). The significance level was set as There were 12 participants in the study, which comprised 9 women and 3 men with a mean age of 32 (21–42) years. Four participants reported unilateral knee pain only (no pain in other bodily areas), four reported additional pain in the back, and four reported additional pain in other bodily areas . Two of the participants also reported pain in the posterior part of the affected knee. The knee pain was most pronounced during activities such as stair climbing, running, and jumping for all participants, but four participants also reported pain during sitting.r = 0.69, p = 0.012). The participants had a lower mean step rate of 19 with the affected leg versus 21 in the asymptomatic leg. Furthermore, 10 of the 12 patients had fewer repetitions with the affected leg compared with the asymptomatic leg. Hence, there was a non-significant difference between the painful knee (PFPS) and asymptomatic knee with a p-value of 0.053 (Wilcoxon signed ranked test)  total score of 52.5 (18). The VAS for the last 14 days and the CRS score showed good correlation  ROM for the onset of pain or discomfort was 123 (72–133) degrees of knee flexion in the affected leg and 127 84–140) degrees in the asymptomatic leg. In the FST, only 2 of the 12 participants had decreased ROM in the affected leg compared to the asymptomatic leg. There was no significant difference between groups for the ROM in either test . The difference was also significant in the FST, with a difference in the NPRS score of 0.70 (p = 0.041). The median pain score was 4.2 in the affected leg and 3.5 in the unaffected leg.Of the 12 patients, 11 reported stronger end-range pain when testing the affected leg compared to the asymptomatic leg in the PKB. The median pain score was 3 (NPRS) in the affected leg and 2 in the unaffected leg. The significant difference was 1 . Two participants had two positive components. A high level of increased mechanosensitivity was found in 4 of 12 patients on the FST test: only one participant had all four components of the FST test positive , while three participants had three out of four components positive.The results revealed somewhat different responses on the two neurodynamic tests when testing the affected and asymptomatic legs. The participants reported stronger pain in the affected leg compared to the asymptomatic leg, particularly when tested with the PKB. Both the PKB and the FST provoked more anterior knee symptoms in the affected leg. Furthermore, all 3 components on the PKB were positive for 8 of the 12 participants . Three or four components of the FST were positive for four participants . Altogether, these findings can be interpreted as signs of increased mechanosensitivity in the femoral nerve in the leg with PFPS.To our knowledge, this pilot study is the first to include both the PKB and the FST when examining patients with PFPS, as well as the first to explore these tests in a clinical setting. The PKB is often used in clinical practice, particularly when examining patients with low back pain, but we also consider this test to be relevant for patients with anterior knee pain. In this small sample of patients with unilateral anterior knee pain, the PKB was more often positive in the affected leg and possibly revealed increased mechanosensitivity in more participants than the FST did. This could be interpreted as greater sensitivity in this test, but the result is not clear. Since no study has explored the methodological quality of the tests, our results must be interpreted with caution.The difference in responses on the two tests could also be due to methodological differences in performing the tests. The FST can be seen as more complex and difficult for the examiner to carry out. The side-lying position makes it more difficult for the examiner to control the spinal flexion and the pelvic stability. According to Shacklock, one common problem is creating sufficient tension in the nervous system through the spinal flexion . This inIt is important to be aware that both tests may induce stress in other tissues like the anterior thigh fascia and muscles and cannot be considered as only testing femoral nerve tension. To exclude the involvement of tissues other than the nerves, the structural differentiation maneuver has been described as essential , 10, 19.One major challenge when using neurodynamic tests is that there is no consensus concerning the operational definitions, how to interpret the responses on the different tests, and how to grade the responses. Therefore, we used four different components to define levels of mechanosensitivity . We compared the affected and asymptomatic legs for each component and interpreted a positive side difference as a sign of altered mechanosensitivity.The 3 or 4 components are often considered when interpreting the tests in clinical practice but have not been used in studies as far as we know. The components are used mainly in accordance with the description from Butler and Shacklock of how to interpret the neurodynamic tests , 10. Butp = 0.003). This difference of 33% exceeds the previously defined MIC, of 30% [p = 0.041), but the MIC did not exceed 30% (17.6%). International consensus literature has suggested that the MIC in NPRS should be 2 [We found a significant but small mean difference in pain on the NPRS between the legs using the PKB  , 31. TheThe study participants had experienced PFPS for more than 3 months and could be characterized as chronic pain patients . ChronicOur pilot study and previous studies have reported that there might be a neurogenic-dysfunction aspect to PFPS –13, 15. Sanchis-Alfonso and Rosello-Sastre found that ischemia in the lateral patellar retinaculum may trigger neural inflammation and could cause anterior knee pain , 35. FurThe main limitation of the present study is the low number of participants. Hence, the results should be interpreted with caution. However, some of our findings are in accordance with results from previous studies. The use of the unaffected leg as an asymptomatic control could be debatable, but this way of preforming the tests is used in daily clinical practice and should be highly relevant for clinicians. The use of two different tests is a strength, and the different findings might indicate that the tests explore different aspects of mechanosensitivity. Hence, the results indicate that both tests should be used in a larger study.It has been shown that the act of repeating the tests can influence the results . We trieIn this pilot study, including patients with unilateral PFPS, we found differences in responses between the affected and asymptomatic legs using two different neurodynamic tests. The results show that it is possible that these patients had increased mechanosensitivity in the femoral nerve in the affected leg compared with the asymptomatic control leg. Particularly, in the PKB, 8 of the 12 participants had a high level of mechanosensitivity in the affected leg. This finding may indicate that altered mechanosensitivity in the femoral nerve can be part of anterior knee pain. Although the reliability of the tests is unknown and the study sample size was small, the PKB and FST test procedures used in clinical practice appear capable of revealing altered mechanosensitivity in unilateral PFPS patients. Hence, the tests may be worth considering when examining PFPS patients. The neurodynamic tests for femoral pain can easily be included in the standard assessment protocol. However, it is important to measure all components carefully and to interpret the findings with caution. Since this is a pilot study, we recommend that both tests should be included in a study with larger samples and a control group of healthy individuals. Further studies are needed to investigate the neurodynamic tests and the relationship between PFPS and mechanosensitivity.


OBJECTIVES/SPECIFIC AIMS: This study seeks to test the feasibility and effectiveness of a brief acceptance and commitment therapy (ACT) treatment for chronic pain patients in a primary care clinic METHODS/STUDY POPULATION: Primary care patients aged 18 years and older with at least 1 pain condition for 12 weeks or more in duration will be recruited. Patients will be randomized into (a) ACT intervention or (b) control group. Participants in the ACT arm will attend 1 individual visit with an integrated behavioral health provider, followed by 3 weekly ACT classes and a booster class 2 months later. Control group will receive enhanced primary care that includes patient education handouts informed by cognitive behavioral science. Data analysis will include 1-way analysis of covariance (ANCOVA), multiple regression with bootstrapping. RESULTS/ANTICIPATED RESULTS: The overall hypothesis is that brief ACT treatment reduces physical disability, improves functioning, and reduces medication misuse in chronic pain patients when delivered by an integrated behavioral health provider in primary care. In addition, it is anticipated that improvements in patient functioning will be mediated by patient change in pain acceptance and patient engagement in value-consistent behaviors. DISCUSSION/SIGNIFICANCE OF IMPACT: This pilot study will establish preliminary data about the effectiveness of addressing chronic pain in a generalizable integrated primary care setting. Data will help support a larger trial in the future. Findings have potential to transform the way chronic pain is currently managed in primary care settings, with results that could decrease disability and improve functioning among patients suffering from chronic pain.