Introduction : Use of Selective Nerve Root Block (SNRB) in lumbar region to relieve radicular pain along the course of a particular nerve is being practiced in the recent past. We observed and tabulated therapeutic outcomes of this procedure in management of radiculopathy induced by a prolapsed disc affecting a particular lumbar nerve root.Methods : 40 patients with various grades of disc prolapse affecting a particular lumbar nerve root presenting with chronic radicular pain were identified irrespective of age and sex. All were injected with a combination of 40 mg of Methylprednisolone based suspension with local anaesthetic over the affected nerve root and results were analyzed.Results : Those graded mild had 4.3 months relief and those graded moderate had 2.5 months relief. Those with severe disc prolapse had no relief except for the immediate postprocedural relief. Only 20% patients had relief up to 6 months.Conclusion : Effect of SNRB is typically short acting in majority of patients and recurrence is expected. It creates a window period with reduced pain but of varied intervals depending on the pathology. It did not alter the prognosis in those with severe disease where surgery is well indicated.Level of Evidence – Level 4 Although its specificity as a diagnostic tool is said to be low, Therapeutic efficacy needs to be debated5. It is used invariably for those with or without significant surgical spinal lesions6. Mechanical lesions include various stages of disc prolapse, ligamentum flavum hypertrophy, facet hypertrophy and degenerative osteophytes causing foraminal stenosis, all leading to nerve root irritation7. Inflammatory response to exposed nucleus pulposus is also said to contribute to the nerve root pain7. The principle behind this technique is to reduce inflammation of the nerve root by injecting a steroid and thus reducing the intensity of pain. But the actual pathology causing the nerve root irritation remains and hence recurrence is expected. Our aim is to study the prognosis after single dose of SNRB over affected lumbar nerve roots and find out whether a window period of reduced pain be achieved before proceeding to next line of management.Lumbar radiculopathy can be defined as pain from lower back radiating until the leg or further beyond along the course of a particular lumbar nerve. Selective Nerve Root Block (SNRB) is practiced as a part of the management of radicular pain due to a particular affected nerve root in both cervical and lumbar regions8.Selection criteria of our patients were irrespective of age and sex. Those patients with complaints of lumbar radiculopathy for more than 3 months demonstrating a positive unilateral Straight Leg Raising test (SLRT) within 30-60 degrees were selected. MRI was done in all patients as a standard protocol to look for mechanical lesions. Only those patients with intervertebral disc lesions affecting a particular lumbar nerve root were selected for the study. Those with more of back pain component than radiating pain were excluded. Those with bilateral symptoms, multiple nerve root involvement and neurological weakness were excluded. We used the MSU Classification for herniated lumbar discs on MRI to grade our patients 8.9. Numeric rating scale (NRS) for pain was used to grade pre procedure pain on doing SLR10. Radiological lesion in 15 patients was type 1B prolapse  for back pain and their score was recorded before the procedureprolapse a and in prolapse b. The reprolapse c where sprolapse . ProceduAll selected patients had previously undergone a course of conservative management with rest and physiotherapy which did not relieve their symptoms. 32 patients had L4-L5 disc prolapse which usually affects the L5 nerve root that traverses at that level and exits below the L5 pedicle. 8 patients had L5-S1 disc prolapse that usually affects the S1 nerve root that exits in the first dorsal sacral foramina. Our sample did not have patients with pathology at any other level except for L4-L5 and L5-S1 and hence our target nerve roots were L5 and S1. None of our patients had a L4-L5 far lateral disc prolapse affecting the L4 root and none had a L5-S1 far lateral disc prolapse affecting the L5 root.Our procedure to target L5 and S1 roots differs. It is always done under C-Arm guidance but the position of C-arm and direction of exposure varies . Patient11. Various patterns of contrast material distribution around the nerve were seen as shown in literature  had L4 L5 intervertebral disc prolapse in whom L5 nerve root was targeted. 8 patients (20%) had L5 S1 disc prolapse in whom S1 nerve was targeted. Mean numeric rating of pain using NRS immediately after the procedure on doing straight leg raising on the affected side was reduced to 4 which is due to the local anaesthetic effect. NRS assessment on doing SLR was done on 2nd day after the procedure for 7 patients who returned with similar pain. It was found to be the same as pre procedural status or one point less. They were given reassurance and were asked to wait until one week is complete for RMDQ score. All patients were reviewed after one week and were given the Roland Morris Disability questionnaire for back pain and their score was noted. Mean overall RMDQ score at 1 week was 10.35 which denote improvement. Those with full recurrence in subsequent follow ups having RMDQ scores more than 20 were excluded from our sample to proceed to next line of management which is not discussed in this article.Even though overall RMDQ score denotes improvement by 1 week, 7 patients had RMDQ Score of 20 or more. These patients were the ones considered severe in whom surgery was indicated but were not willing to proceed with immediate surgery. All these patients had full recurrence after 1st week with RMDQ score of 22 or more. They were explained about their poor outcome and all of them opted for a surgical decompression. On excluding those 7 patients with recurrence our sample reduced to 33 patients (82.5%) with a mean RMDQ score of 8.1 by 2 weeks and 6.2 by 3 weeks. Review at one month had 4 patients with RMDQ scores more than 20. Hence they were excluded for further management reducing our sample size to 29 patients (72.5%). The mean RMDQ score of the reduced sample was 7.8 by 1 month.Next follow up was by 2 months which had 10 patients with RMDQ scores more than 20. They were excluded and our group reduced to 19 patients (47.5%) with mean RMDQ score of 6.8. Six patients had recurrence at 3 months reducing our group to 13 (32.5%). Mean RMDQ score of the remaining 13 was 9. By 4 months, 5 more patients had RMDQ score more than 20. Hence our group reduced to 8 patients (20%) with mean 4 month RMDQ score of 8.4. These 8 patients were seen at 5 months with mean RMDQ Score of 11.8 and at 6 months with mean RMDQ score of 15. Patients with non-surgical radiological lesions who had symptoms after 6 months were given choice of a 2nd dose SNRB and all of them opted. They were explained about our results and prognosis.Analyzing results showed that 82.5% patients had improvement by 2 weeks which reduced to 72.5% by 1 month . SequentLumbar radiculopathy is a very common condition seen in our orthopaedic clinic. We see an increased incidence in patients presenting with this condition. Conservative management in these patients is highly unpredictable. Most patients do not accept surgery in first place and there are circumstances where we feel surgery is not yet indicated. Such patients require something that will relieve their pain at least for a short duration. SNRB plays an important therapeutic role in these patients. As the actual pathology causing the nerve root irritation remains, prognosis in these patients varies.12. Triamcinolone and betamethasone based preparations are also in use13. Easy availability in our institute made us to choose a methyl prednisolone based aqueous suspension for this purpose. For obtaining therapeutic effect, we used 40 mg of steroid for one SNRB. To be more precise, we always looked for paresthesia when the needle touches the nerve root and then withdrew the needle slightly before injecting the dye. Care is taken not to handle the needle vigorously when around the nerve root as we expect a mere touch with the root. Most authors say that this should not be done to prevent needle induced complications but we did not have any such complications11, 14.Many authors have used methyl prednisolone based preparations for this purpose10. The pain rating can be obtained by asking the patient to choose a number between 0 to 10 with 0 being no pain and 10 being severe pain. But our main aim was to concentrate on the functional outcome and hence we used the Roland Morris Disability Questionnaire15. This method is useful in circumstances when the patient is not able to come for follow up. It has a set of 24 questions that is asked to the patient mainly on functional aspects. Patients just need to reply yes or no for this questions hence a telephonic conversation with the patients is enough to collect data. The higher the number of Yes, the severe is the problem. Clinical improvement over time can be graded based on the analysis of serial questionnaire score15.We used the numeric pain rating scale for pre procedural and post procedural assessment of pain11. There were patients with severe pain during first follow up who gradually improved and there were also patients with good relief gradually worsen. Those with severe disc prolapse who were not willing for surgery neither responded nor gained any interval period with reduced pain except for the immediate post procedural relief. This immediate relief can be considered as a diagnostic tool to confirm that the blocked root is the affected one that needs to be decompressed. It correlates with the amount of relief the patient will have if that particular nerve root is decompressed surgically. Those with mild and moderate prolapse showed similar results gaining them an interval period with reduced pain which allowed most of our patients to think about next line of management if their pain comes back.As noted by few other authors, early response did not predict the effect after 2 weeksThe effect is typically short acting in majority of patients yet it gains a valuable interval period of reduced pain in those patients with mild and moderate pathology. This procedure can be effectively used as an intermediate procedure before going for surgery in those patients with inconclusive radiological indication for surgery. It does not alter the prognosis in those with severe disease where surgery is well indicated.


Objective. The aim of this study was to compare the efficacy of ultrasound-guided deep cervical plexus block with fluoroscopy-guided deep cervical plexus block for patients with cervicogenic headache (CeH). Methods. A total of 56 patients with CeH were recruited and randomly assigned to either the ultrasound-guided (US) or the fluoroscopy-guided (FL) injection group. A mixture of 2–4 mL 1% lidocaine and 7 mg betamethasone was injected along C2 and/or C3 transverse process. The measurement of pain was evaluated by patients' ratings of a 10-point numerical pain scale (NPS) before and 2 wks, 12 wks, and 24 wks after treatments. Results. The blocking procedures were well tolerated. The pain intensity, as measured by NPS, significantly decreased at 2 wks after injection treatment in both US and FL groups, respectively, compared with that of baseline (P < 0.05). The blocking procedures had continued, and comparable pain relieving effects appeared at 12 wks and 24 wks after treatment in both US and FL groups. There were no significant differences observed in the NPS before and 2 wks, 12 wks, and 24 wks after treatment between US and FL groups. Conclusions. The US-guided approach showed similar satisfactory effect as the FL-guided block. Ultrasonography can be an alternative method for its convenience and efficacy in deep cervical plexus block for CeH patients without radiation exposure.  Cervicogenic headache (CeH) is a common diagnosis for patients with unilateral referred pain to the head from the upper cervical spine . The pre2-C3 zygapophysial and atlantoaxial joints are believed to be primary causes for CeH and the C2 nerve may be more susceptible to injury by aseptic inflammation or compression than the other structures [The Cructures –11. Realructures –14. Howeructures –18.The objective of this study was to evaluate the efficacy of ultrasound-guided deep cervical plexus block for patients with CeH in comparison with fluoroscopy-guided block through a prospective, randomized, single-blind clinical trial.n = 30) or fluoroscopy-guided  C2 and/or C3 transverse process injection, respectively, in the pain center of Sun Yat-sen Memorial Hospital from July 2011 to January 2014. The study was approved by our university and all patients gave informed consent before this study.There were 84 eligible patients with CeH and 60 patients participated in this randomized, single-blind study. They were enrolled and then randomly assigned into two groups according to a random number table and underwent ultrasound-guided , and (5) headache frequency of at least 1 per week over a period greater than 3 months. In this study, we chose the patients with unilateral pain. Our exclusion criteria included (1) pathologic fracture, cancer, and other diseases of the cervical vertebra, (2) headache caused by nervous system diseases, or other factors.The patients had experienced screening that included medical history and physical examination followed by X-ray, CT scan, or MRI of the cervical spine. All patients were diagnosed with CeH according to the diagnostic criteria of Sjaastad et al. : (1) uni2 or C3 was identified on the ultrasound image . If necessary, the patients would receive the second injection in one-week interval after the first injection. All procedures were performed in the same fashion by C. M and HY. Y.The patients were placed in sitting position with the neck bending forward and the head was supported . The selnd image . Then, tme level . A 22-ga Figures . When th2 or C3 spinal process was identified on the lateral view . Pain was assessed before the injection and the return visit was conducted in 2 weeks after treatment to exclude any major complications. All the patients were followed up at 12-week and 24-week intervals with telephone consultation and visits to the pain clinic.χ2 test and Mann–Whitney U method. At each time point of injection, the NPS was compared by repeated-measures analysis of variance, and the Bonferroni correction was conducted for post hoc comparison. Statistical analysis was carried out using SPSS 16.0 . Values are expressed as means ± SD and a P value of less than 0.05 was considered to be statistically significant.The pain intensities were measured on a 0–10 NPS. The characteristics of the US and FL groups such as sex, age, and duration of pain were compared by the n = 28, 7 males and 21 females) completed the injection and 12 patients received the second injection treatment. In FL group, one patient chose other noninvasive interventions and three patients were lost in the follow-up because of refusal to radiation exposure; a total of 26 patients  completed this study and one-half of them received the second block. The patients had comparable pain duration for 10.06 ± 3.47 months as that of US group. The majority of location of the block was the C2 transverse process (71.43% in US group and 80.77% in FL group). The demographic data of patients are present in A total of 84 consecutive patients were assessed for eligibility during this study, with 60 of them being enrolled and 54 patients completing the study. A flow diagram with patient selection and follow-up is presented in The blocking procedures were tolerable for all the patients during the treatment. However, 3 patients in US group felt dizzy immediately after injection; the symptom disappeared when they lay down on the bed for several minutes. A total of 4 patients (2 in US group and 2 in FL group) complained of neck and shoulder uncomfortableness. None of the patients in this study had any treatment-related severe complications. There were 25 patients (12 in US group and 13 in FL group) who received the second injection according to their symptoms at the return visit.P < 0.05). The blocking procedures had continued, and comparable pain relieving effects appeared at 12 wks and 24 wks after treatment in both US and FL groups (P < 0.05) and at 2 wks after injection (P < 0.05). It indicated that steroid injection guided by either ultrasound or fluoroscopy had sustained pain-relieving effect for CeH patients.There were no significant differences observed in the NPS before and 2 wks, 12 wks, and 24 wks after the injections between US and FL groups . The paiL groups , the NPS2-C3 and C3-C4 z-joints, A-A joint, C2-C3 intervertebral disk, A-O joint, and the greater or lesser occipital nerve [2 becomes the greater occipital nerve after passing the posterior aspect of the C1/2 facet joint. The C2 and C3 ventral rami become the lesser occipital nerve, and the C3 dorsal ramus becomes the third occipital nerve [2/3 facet joints [2 and/or C3 transverse process steroid injections were applied to 54 patients with CeH and comparable pain relief effect was observed. It has been frequently demonstrated that blockade of the greater occipital nerve, the lesser occipital nerve, the stellate ganglion, and other various blocking treatments are effective strategies for CeH. Zhou et al. reported that, of the 28 CeH patients, 26 of them had abnormalities in the cervical spine below the C1/2 and C2/3 levels and C1/2, C2/3 facet joint injections and C2, C3 spinal rami blocks were effective and well tolerated by the patients [Cervicogenic headache is a common clinical syndrome and few conservative managements lead to satisfactory clinical efficacy. There are multiple causes of CeH, including the Cal nerve . Anatomial nerve , 11. Thet joints . In thispatients . Our res2 and/or C3 transverse process block technique is a modification of the deep cervical plexus block that has been utilized to provide anesthesia to the head and neck region [The Ck region . This tek region , which aThe FL-guided injection procedure is most commonly used in treating pain-associated diseases to ensure correct needle placement. However, radiation exposure was unavoidable, and there is a risk of vertebral artery injury. The US-guided method has several advantages in comparison with the FL-guided method. Gofeld et al. explored US-guided lumbar transforaminal and z-joint injection techniques for patients with spinal pain, and their studies demonstrated that US-guided injections are accurate and feasible , 24. It The main limitations of the study are as follows: first, the sample size was small; thus, clinical findings still need to be confirmed with larger clinical trials. Second, this study was not a double-blind control study. It was difficult to conduct a double-blind control study with nontraditional modalities such as ultrasound and fluoroscopy. Additional investigations may be needed to improve the limitations.2 or C3 transverse process for treating patients with cervicogenic headache provided significant and prolonged pain relief (6 months' follow-up). The US-guided approach showed similar satisfactory effect as the FL-guided block. Ultrasonography can be an alternative method for its convenience and efficacy in deep cervical plexus block without radiation exposure.In summary, deep cervical plexus block in C


The aim of the present paper is to assess the gait pattern of patients with Peripheral Artery Disease (PAD). A more specific aim is to compare the gait pattern of PAD patients before and after the appearance of intermittent claudication symptoms.The study involved 34 PAD patients with a claudication distance ≥200 m and 20 participants without PAD, who formed the control group. The gait pattern of PAD patients was assessed twice: before the appearance of intermittent claudication symptoms (pain-free conditions) and after the appearance of intermittent claudication symptoms (pain conditions).p = 0.008) and in pain conditions . As for the remaining spatiotemporal parameters, there were no differences observed between the patient group and the controls. Intermittent claudication symptom induced by the walking test on the treadmill did not bring about any new abnormalities in the gait pattern or intensify the existing abnormalities of the gait.Compared to the control group, PAD patients presented a statistically significant decrease in step length both during pain-free conditions (52.6 ± 12.5 vs. 72.8 ± 18.5 cm, PAD patients have a tendency to shorten their step length regardless of the presence of intermittent claudication. The most frequent symptom of PAD  is intermittent claudication. It manifests itself through pain occurring in one or both lower limbs during physical exercise, and its growing intensity forces the patient to rest. The pain in lower limb muscles is connected with temporary ischaemia caused by arterial occlusion or stenosis. The location and extent of arteriosclerotic lesions determine the location of pain in the lower limbs experienced by the patient –3.Currently, it is believed that PAD patients move more slowly and tend to take shorter steps compared to the healthy population , 5. It iGait abnormalities in PAD patients have not yet been explicitly explained. Chen et al. suggest that these abnormalities may be a consequence of weakened back thigh muscles and shin muscles. According to their study, the weakening of these muscles affects the acetabulofemoralor hip joint and ankle mobility, resulting in a slower and heavier gait . The losA controversial issue regarding the gait of PAD patients is the moment at which the pattern of gait is altered. According to some authors, gait abnormalities in PAD patients can be observed both during pain-free and pain conditions, and the appearance of intermittent claudication symptoms only intensifies the existing pathology , 12. OthThe study involved 54 subjects aged 55–65. Thirty-four participants were PAD patients (stage IIa of the disease according to the Fontaine classification) treated at the Clinic of General and Vascular Surgery, Karol Marcinkowski University of Medical Sciences, Poznań. The patients qualified for the research included those with one-sided and two-sided symptoms. The control group consisted of 20 participants without PAD, whose age was similar to that of the members of the patient group. The inclusion criteria for the control group were: lack of pain in lower limbs and no history of ruptures or surgical interventions. The control group was recruited from among participants of courses at the University of the Third Age in Poznań.The following inclusion criteria were adopted: exertional pain in the lower limbs reported by the patient and confirmed in a diagnostic walking test, walking distance ≥ 200 m, resting Ankle Brachial Index (ABI) ≤ 0.9, age 55–65, and written informed consent to participate in the study.2); mental disease or dementia obstructing contact with the patient and simultaneous participation in other clinical trials.Conditions regarded as criteria excluding the patient from the research included: a symptom-free course of PAD; walking distance < 200 m; the technical inability to assess ABI; the inability to walk on the treadmill; diabetes; joint disorders obstructing motion; amputation of a lower limb; ulceration of the lower limbs; a stroke suffered within 6 months prior to the study; acute coronary syndrome, coronary artery bypass surgery or endovascular angioplasty of coronary arteries within 12 months prior to the study; surgical or endovascular intervention in the lower limbs within 12 months prior to the study; aortic aneurysm; advanced kidney or liver failure, failure of the respiratory or circulatory system; active neoplastic disease; advanced, chronic venous insufficiency; Buerger’s disease; uncontrolled hypertension; obesity  with the use of the Gardner protocol with a gradually increased grading. The treadmill velocity was 3.2 km/h and remained constant. During the first two minutes, the patients walked on a flat surface, without any grading of the treadmill. The grading was increased by 2% every two minutes until the maximum grading of 12% was reached. For each patient, the pain-free walking distance was measured, as well as the maximum claudication distance.The assessment of spatiotemporal parameters of gait was performed with an optical system of movement analysis Optogait  –23. The Bearing in mind that walking on a treadmill is not a natural way of moving for humans, each participant was familiarized with this type of walking prior to the gait analysis. Following the guidelines set out by Mika et al., the gait analysis was preceded by a six-minute warm-up on the treadmill. The study by Mika et al. showed that changes in the gait biomechanics occur during 6 min of walking on a treadmill. After this time, the differences between repeated measurements of specific gait parameters cease to be statistically significant . In our The gait pattern in pain-free conditions was analyzed first. Participants reported the moment when the first symptoms of intermittent claudication appeared, which was recorded in the test report and was treated as completing the first stage of the test. The second gait pattern analysis was performed when the ischemic pain reached moderate intensity, assessed by the participant as level 4 pain on a 5-point scale of claudication . In the control group, the gait pattern examination continued for 10 min. Members of the control group walked on the treadmill at their preferred speed.the proportional share of the swing and stance phases,the proportional share of the single support phase and double support phase,walking speed [m/s],step length [cm],cadence,gait cycle duration [s].The following spatiotemporal parameters of gait were assessed:The assessment of the subjective functional capabilities connected with gait was performed with the use of the Walking Impairment Questionnaire (WIQ). The following three domains were assessed: claudication distance, walking speed, and the ability to go up and down stairs. The scoring for each question featured a scale from 0  to 4  .Statistical analysis was performed with the Shapiro-Wilk test. The Mann-Whitney test was used to assess the parameters for which a non-parametric distribution was obtained. The Wilcoxon signed-rank test was used to compare non-parametric dependent variables. In the case of parameters for which the distribution was close to normal, Student’s t-test was used for the dependent and independent variables. The results obtained by the patient group were compared with the results obtained by the control group . The patients’ ability to walk faster might have stemmed from the shorter disease duration (16 months vs. 72 months). What is more, in the study by Gommans et al., the gait pattern analysis was performed when the ischemic pain reached the intensity described by the patients as “between moderate and intense” . It mighThe results obtained are partially compatible with the findings of McCully et al., who also observed a shorter step length in PAD patients. However, contrary to our findings, they observed this abnormality only after the appearance of intermittent claudication symptoms. Moreover, in their research, the ischemic pain in the lower limbs caused a decrease in the patients’ walking speed, which was not observed in the present study. This difference between the two studies may stem from the use of different measurement devices. To measure the spatiotemporal parameters of gait, McCully used the Gait Mat system, which is a high-resolution, advanced floor mat with built-in sensors to capture plantar pressure and forces . In our McCully’s results are in line with those obtained by Gardner, who analyzed the spatiotemporal parameters of gait with the use of a similar measurement device (GAITrite system) , 8. GardSlightly different results are reported by Chen et al., who observed gait abnormalities in PAD patients both during pain-free and pain conditions. Their complex assessment of gait included the analysis of kinetic and kinematic values. Compared to the control group, patients with PAD walked with a lower speed and made shorter steps during pain-free conditions. They also presented an increased cadence of gait and an elongated duration of the double support phase. The ischemic pain in the lower limbs intensified the existing speed and step length abnormalities of gait .On the other hand, Scherer’s research indicates that, despite the limited walking distance and lower quality of life, patients with PAD do not show any abnormalities of the gait pattern. Scherer compared the results of the patient group with the results of participants without PAD, who formed the control group. Although PAD patients obtained worse results in the walking test and in the SF-36 questionnaire, no differences in the gait parameters were observed. The assessed parameters included step length, cadence, and foot rotation angle both during walking with a preferred speed and during a quick march. It should be noted that intermittent claudication symptoms were not induced by the walking test in any of the patients. The assessment was performed only during pain-free conditions .Different results obtained by the authors mentioned above seem to be the result of using different measurement devices. Although all these authors used objective methods of gait analysis, one needs to be aware of the differences that affect the quality of the assessment: methods of obtaining data, the walking surface , the positioning of markers, and the experience of the research team. The Optogait system, although a relatively new technology, is considered a credible and reliable method of analyzing gait both in physiological and pathological conditions –23, 30. It should also be noted that the majority of authors do not report on the intensity of ischemic pain recorded during the gait pattern analysis. In the present study, the analysis of the gait pattern was performed when the ischemic pain reached moderate intensity, assessed by the patients as level 4 on a 5-point claudication scale. Throughout the duration of the tests, we avoided inducing the maximum ischemic pain, which is always a source of great discomfort to patients and activates an inflammation cascade. It may be presumed that with severe ischemic pain, the gait pattern is disturbed in a much more dramatic way than the gait pattern observed in patients experiencing mild/moderate pain.The main limitations of the present study included its small population of participants and the inclusion of patients with symptoms in one and both lower limbs. Both limitations resulted from the extensive list of exclusion criteria. Another potential limitation of the study is that it assessed only selected spaciotemporal gait parameters, which do not reflect the entirety of the description of gait. Further research is required to investigate the subject in greater detail.An important asset of this research was the homogeneity of the group of participants as regards the walking distance. Participants included in the study suffered from stage IIa of the disease according to the Fontaine classification. To standardize the functional condition of patients, the research excluded patients with a critical lower limb ischemia, patients without any symptoms of intermittent claudication, and patients for whom the walking distance was < 200 m. Another merit of the present research is the assessment of multiple spatiotemporal parameters of gait. Besides gait speed and step length, which are among the most frequently assessed gait parameters, we also analyzed the proportional share of particular phases of the gait cycle.The gait pattern of PAD patients is abnormal and characterized by a shorter step length. The appearance of intermittent claudication symptoms during the walking tests does not intensify the existing abnormalities or contribute to the formation of any new abnormalities of gait.


Dry needling (DN) and percutaneous electrical nerve stimulation (PENS) are widelyused techniques in the treatment of myofascial pain.To investigate the immediate and short-term effects of the combination of DN andPENS compared to DN alone on the upper trapezius muscle.This is a 72-hour follow-up single-blinded randomized controlled trial. Sixty-twovolunteer patients with chronic myofascial neck pain with active MyofascialTrigger Points (MTrPs) in the upper trapezius muscle were recruited. Randomizationwas performed, and 31 patients received DN treatment (DN group) and 31 received DNand PENS (DN+PENS group). The primary outcomes were neck disability index (NDI)and visual analog scale for pain for both post-needling soreness (PNS) and neckpain intensity (NPI). Pressure pain threshold (PPT) and cervical range of motion(CROM) were the secondary outcomes. We detected between-group differences in NPI and PNS in favor of the DN+PENS groupimmediately after treatment. No between-group differences in NDI wereobserved.PENS application after dry needling treatment is more effective than dry needlingalone for decreasing soreness in the short term and improving neck pain intensityimmediately in patients with myofascial chronic neck pain. The application of PENS after DN to active myofascial trigger points shows higherhypoalgesic effects than DN alone, reducing post-needling soreness immediately andin a short-term follow-up. There was no difference in terms of disability.The combination of PENS and DN has an immediate hypoalgesic effect, reducing neckpain intensity in myofascial chronic neck pain patients. However, both DN and thecombination of DN and PENS reduce neck pain in a short-term follow-up.Given that both DN and the combination of DN and PENS decrease neck pain, it isrecommended that the combination (DN+PENS) be applied in order to avoidpost-needling soreness, which is the most common secondary side effect.Myofascial pain is commonly defined as a frequent source of pain in clinical practice.Myofascial pain is a prevalent pathology in developed countries, with epidemiologicalstudies showing that up to 85% of the general population will experience at least oneepisode of myofascial pain during their lifetime,Myofascial trigger points (MTrPs) are often present in this pain-related pathology andare defined as hypersensitive spots located in the palpable taut bands of skeletalmuscle,,Many non-pharmacological techniques are applied for the treatment of MTrP worldwide,,,-,Additional techniques have been combined with DN to inhibit MTrPs and reducepost-needling soreness. For example, ischemic compressionThe objective of this study was to assess the effectiveness of a combined treatmentusing PENS with DN approach, versus DN alone, on improving post-needling soreness, neckpain, neck disability, pressure pain threshold (PPT), and cervical range of motion(CROM) in chronic neck pain patients with active upper trapezius MTrPs.This is a single-blinded randomized controlled trial. The outcome assessor did not knowthe group to which the subject was allocated. Sample size calculation were performedusing G*Power software version 3.1.7 Participants were excluded if they presented any of the following criteria: (1) previoustreatment of DN; (2) radiculopathies and/or radicular pain; (3) whiplash-related neckpain; (4) dizziness; (5) migraines; (6) previous cervical surgical intervention; or (7)diagnosis of fibromyalgia.A blinded researcher performed the randomization of subjects, using the statisticalprogram GraphPad , obtaining two blocks of 31subjects, corresponding to each group of treatment. Only the therapist had access to theallocation schedule. Due to the nature of the interventions, both patients and treatmentprovider were not blinded to the treatment allocation.This trial was approved by the Ethical Committee of Rey Juan Carlos University, Madrid,Spain, with identification number 50/2012. This study was also registered under numberNCT02230709. All subjects signed an informed consent form before their inclusion.The primary outcomes were pain intensity for post-needling soreness and neck painintensity as well as disability. All other outcomes were considered secondary.Using a pain diary, post-needling soreness was measured at 24, 48, and 72 hpost-treatment. Neck pain intensity was measured before DN, immediately after DN andat 72 h post-treatment. The degree of disability was registered before DN and at 72 hpost-treatment. PPT and CROM were assessed before DN, immediately after DN, and at 72h post-treatment.A VAS scale was used for measuring pain intensity. This scale consisted of a 10 cmlong line, where the 0 cm point corresponds to “no pain” and the 10 cm pointcorresponds to the “worst imaginable pain”. The patients placed a vertical markcorresponding to their level of pain. The Numerical Rating Scale (NRS) may also beused to measure pain score. Both methods have been demonstrated to be reliable andvalid instruments for the measurement of neck painPost-needling soreness was quantified using a pain diary with a visual analog scale.The patient completed the diary by registering in the VAS the pain intensity in theneedled area four times per day  during the three days following treatment. Subjects were asked tospecifically rate the post-needling soreness separately from the original myofascialneck pain.The validated Spanish version of the Neck Disability Index (NDI) was used to assessthe degree of disability. The NDI is a valid tool for the measurement of pain andself-assessment of cervical disability. The NDI is composed of 10 questions relatedto daily functional activities. NDI presents an acceptable reliability with anintraclass correlation coefficient (ICC) ranging from 0.50 to 0.982. PPTis defined as the minimal amount of pressure that induces pain. A physical therapistwith 3 years of experience in algometry took three measurements at 30-sec intervals;the mean of the three measurements was used in subsequent analyses. PPT presents highinterexaminer reliability with an intraclass correlation coefficient (ICC) of 0.91and high intraexaminer reliability (ICC=0.94-0.97) in the upper trapezius musclePressure Pain Threshold (PPT) was assessed using a digital algometer  that reported measurements in kg/cm,Cervical Range of Motion (CROM) was measured using a cervical goniometer . Subjects performed neck movements to thefullest extent of their mobility of flexion, extension, right and left lateroflexion,and right and left rotation. The mean of three measurements was calculated for eachmovement. CROM presented a good intraexaminer and interexaminer reliability with aICC>0.80Subjects in the first group (DN group) received deep DN to the upper trapezius activeMTrP until two local twitch responses were elicited. The physical therapistpreviously disinfected the area and performed deep DN based on the method describedby HongSubjects in the second group (DN+PENS group) received deep DN to the upper trapeziusactive MTrP until two local twitch responses were elicited and PENS was appliedimmediately after, using a portable TENS device  with the needle as the negative electrode. A second electrodewas an adhesive one, and it was placed 1 cm lateral to the positive electrode. Theparameters used were a compensated symmetrical pulsed biphasic current of lowfrequency (2 Hz) and a pulse width of 120 μs applied over a 15 min period. Thepatient was asked to indicate when the current intensity was well tolerated and notpainful.The statistical analyses were carried out using the SPSS statistical software systemversion 20.0 . Using the Kolmogorov-Smirnov test, CROMwas found to be normally distributed, whereas VAS, PPT, post-needling soreness, andNDI variables were not normally distributed. Descriptive statistics were used tosummarize data, including means and SDs, medians, and interquartile ranges forcontinuous data. A 2×3 repeated measures ANOVA was performed to evaluate the effectof the CROM variable with intervention  and time as factors. Testsof within-patients post hoc sample effects  were performed with Bonferroni corrections. TheMann-Whitney U test was used for the analysis of the NDI variable. For the remainingvariables, between-group differences were assessed by the Kruskal-Wallis test. TheWilcoxon signed rank test was used for post hoc within-group comparisons. Statisticaltests were interpreted at the 5% significance level. The analyses followed theintention-to-treat principles.Sixty-two patients successfully completed the study protocol, of which 31 wererandomly assigned to the DN Group  and 31were assigned to the DN+PENS Group . Atotal of 30 subjects were analyzed in the DN Group and 29 subjects were analyzed inthe DN+PENS Group .The patients’ demographic and clinical characteristics at the beginning of the studyare summarized in For the between-group comparisons using the Kruskal-Wallis test, differences werefound at all follow-up periods (P<.05), showing greater improvements in theDN+PENS group. The post-needling soreness findings are presented in In the between-group comparison using the Kruskal-Wallis test, differences werefound in the immediately post-treatment measures (P<.05), showing a decrease inVAS scores for DN+PENS group .In the between-group comparisons (Mann-Whitney U test), no significant differencesin NDI were found at 72 h post-treatment (P>.05) .Both groups presented no statistically significant differences in PPT betweenbaseline and all follow-up periods (P>.05.). In the between-group comparisons, differences were found at the immediate post DN (P<.05),showing a higher improvement in the DN+PENS group .Repeated measures ANOVA findings for CROM outcomes were as follows: The time ×group interaction did not show statistical significant changes in any of themovements , so no differences between group were found..This study has found that combined DN plus PENS treatment significantly outperformed DNalone at reducing post-needling soreness in the first 72 h after treatment. Moreover,after a single session of DN on the trapezius muscle, neck pain intensity was decreasedat 72 h post-treatment, but not immediately after treatment. However, when PENS wasincluded, neck pain intensity was decreased immediately post-treatment and at 72 hpost-treatment. This reduction was significantly greater than the improvement producedby DN alone. Both groups improved in disability, regardless of whether PENS was applied.Only within-group differences were found in extension and lateroflexion in both groupsat the 72 h follow-up.The additional use of PENS immediately following DN resulted in a significantlygreater reduction in post-needling soreness compared to DN aloneRegarding latent MTrPs, recent studies have shown that the application of ‘spray andstretch’In our study, patients in the DN+PENS group obtained greater improvements in neckpain than those who received DN alone. The immediate neck pain decrease in theDN+PENS group was 2.5 cm, which is greater than the minimum change accepted as likelyto be clinically relevant (2 points or 2 cm)-Neck disability decreased significantly from baseline after the application of bothDN and the combination of DN and PENS. No significant differences were foundbetween-groups. These results are in line with previous DN studies that have reportedfunctional improvements in myofascial pain patientsMechanical hypoalgesia was found immediately after treatment in the DN+PENS group,but not in the DN group, with the between-group differences being statisticallysignificant in favor of the DN+PENS group.2, which reached the minimal detectable change (defined as between0.47 kg/cm2 and 1.2 kg/cm2)The improvement in PPT scores after treatment in the DN+PENS group was of 0.77Kg/cm,These findings demonstrate that the application of PENS combined with the DNtechnique decreases the mechanical pain in the needled area. When only DN isperformed, hypersensitivity is developed, so the PPT decreased among the DN groupsubjects. Recent studies using various frequencies of TENSThe application of PENS after DN did not significantly increase CROM, when comparedto the DN group. A recent study assessed the effectiveness of MTrP lidocaineinjection combined with ischemic compression  in thetreatment of active MTrPs in the trapezius muscle,Regarding within-group analysis, only the DN+PENS group showed significantimprovements in CROM from baseline in the extension and lateroflexion movements.However, these results are limited in relevance because the CROM improvements did notreach the minimum detectable change reported by Audette et al. for subjects with neckpain (5.1º for extension and 6.5º for flexion)The current study has some limitations. First, treatment was only performed in the uppertrapezius muscle. Although this muscle is a common source of neck pain, additionalmuscles could also have been evaluated. Second, as there was no placebo group, we cannotexclude a possible placebo effect of PENS or DN. Third, in this study PENS was appliedfor 15 min; however, doses greater than 20 min have been reported to produce analgesiceffects. It would be interesting to apply greater doses of PENS in future studies.The application of PENS after DN showed greater short-term improvements in post-needlingsoreness, neck pain, and mechanical hyperalgesia than DN alone, which leads to theconclusion that the combination of PENS and DN is more beneficial immediately followingtreatment than applying DN alone in patients with chronic myofascial neck pain.Therefore, PENS could be recommended in order to reduce post-needling soreness after theapplication of deep dry needling.


Duloxetine, Etoricoxib and opioid are of the commonly administered drugs in Lumbar laminectomy. The aim of this study is to assess the effect of perioperative use of Duloxetine in combination with Etoricoxib on postoperative pain and opioid requirements.One hundred twenty patients with ASA physical status were enrolled with age between 18 and 70 years. Patients were divided randomly into four groups of 30 patients: group P received placebo, group E received etoricoxib 120 mg, group D received duloxetine 60 mg and group D/E received duloxetine 60 mg capsules and etoricoxib 120 mg; 1 h before surgery and 24 h after.Neither Duloxetine nor etoricoxib individually had effect on pain with movement, while their combination revealed a significant reduction in pain scores over the entire postoperative period at rest and on movement. Etoricoxib showed a significant decrease in pain at all times at rest when compared with group P, while it showed significant pain decrease only at 0, 2 and 4 h when compared with group D. On the other hand duloxetine alone showed significant decrease in pain at rest at 24 h and 48 h when compared with group P. ConcerningMorphine requirement after 24 h.; it wassignificantly lower in the D/E group in comparison with groups P, E and D. It should be noted also that there was a significant decrease morphine requirement in both groups E and D.The perioperative administration of the combination of etoricoxib and duloxetine improved analgesia and reduced opioid consumption without significant side effects.ISRCTN48329522. 17 June 2017 Postoperative pain is mediated by different mechanisms at multiple neural sites. Thus, multimodal analgesics can reduce the postoperative pain . AlthougRecently, antidepressants such as duloxetine, a selective serotonin and norepinephrine reuptake inhibitor (SSNRI), have accomplished pain relief in persistent and chronic pain as in fibromyalgia, postherpetic neuralgia, diabetic neuropathy , osteoarAnother group of analgesics isthe non-steroidal anti-inflammatory drugs (NSAIDs) which are used for acute pain management. It has pain-relieving, antipyretic, and anti-inflammatory properties . It’s thEtoricoxib is more highly selective of COX-2 over COX-1 than celecoxib , and chaThe main objective of the present study was to examine perioperativelythe analgesic efficacy with the combination of duloxetine and etoricoxib on postoperative pain and itsopioid-sparing properties when given as part of a multimodal pain strategy in patients undergoing surgery on the lumbar spine. In addition toevaluating the patient’s satisfaction and the adverse effects related to the combination of both medications.After institutional Ethics Committee approval, this prospective double-blind, randomized, controlled study was started in November 2015 at the department of anesthesia and intensive care unit; El- Minia University Hospital. The study involved 120 adult patients of both genders aging between 18 and 70 years of age with an ASA physical status of I, II and III,who were scheduled for single level lumbar spinal disc prolapse surgery. All patients gave written informed consent.Exclusion criteria involved patients with history of allergic reaction to any of the study drugs, history of drug or alcohol abuse, and abnormal renal or liver function tests. Patients using antidepressants had to stop taking them 2 weeks before surgery. Also, Patients with previous cervical surgeries, psychiatric disorders and patients receiving opioid analgesic medications within 24 h preoperatively were excluded.We asked the patients to visit the outpatient clinic 1 day before surgery for assessment and performing laboratory investigations. We also explained to them the study protocols, including analgesic administration and the11-point numeric rating scale (NRS) where 0 being ‘no pain’ and ‘10’ being the maximal worst pain .The Group P (Placebo) received placebo capsule + two placebo tabletThe Group E (etoricoxib) received placebo capsule + two etoricoxib tablet 60 mgThe Group D (duloxetine) received duloxetine capsule 60 mg + two placebo tabletThe Group DC (duloxetine + etoricoxib) received duloxetine 60 mg capsules + two etoricoxib tablets 90 mgThe patients admitted to the hospital were randomized according to the computer-generated random numbers with closed-sealed envelopes into one of the four groups 30 patients each. The study medications were prepared by the pharmacy of the hospital and given to the patients by an investigator not involved in the study. They were duloxetine 60 mg capsules , etoricoxib 60 mg film coated tablets , and placebo capsules that matched the duloxetine capsules or etoricoxib tablet in color and size. All drugs were given 1 h before surgery and repeated after 24 h.On arrival to the operating room,standard intraoperative monitoring includedelectrocardiogram (ECG), heart rate (HR), mean arterial blood pressure (MABP), oxygen saturation (SPO2) and end tidal CO2 were recorded and subsequent measurements were recorded every 5 min till the end of the operation using a multiparameter monitor .General anesthesia was induced by (1.5 μg/kg) fentanyl IV, (2 mg/kg)propofol IV, and endotracheal intubation was performed with (0.5 mg/kg) IV atracurium. Maintenance of anesthesia was done through inhalation of a mixture of oxygen (3 L/min) (1–2%) isoflurane and (0.05 mg/kg) atracurium as intermittent dose of muscle relaxant to ensure proper muscle relaxation during the procedure.An anesthetist who was blinded to the groups took all the measurements. Their goal was to adjust the anesthetics concentration to keep the heart rate and blood pressure within 20% of the base line value throughout the anesthesia period.At the end of surgery, the first dose of paracetamol 1000 mg/100 ml intravenously  was given to all patients before extubation. Then, reversal of neuromuscularblockade was performed with atropine (0.01 mg/kg) and neostigmine (0.05 mg/kg) given intravenously. After tracheal extubation, patients were transferred to the post-anesthetic care unit (PACU) where vital parameters were recorded every 1/2 h till complete recovery.During the first 48 h, a standard analgesic regimen of paracetamol 1 g was given intravenously every 6 h to all patients. In addition, pain assessment in the ward was performed by nurses every 2 h and titrated doses of morphine  were given if patients reported pain (NRS was ≥3).The postoperative data were collected by a senior resident (blinded to the study). The NRS pain scores was recorded at 30 min after the end of anesthesia (time = 0), all patients were able to answer questions and to rate their pain score at the end of 2, 4, 6, 12, 24 and 48 h postoperatively in the ward. Pain assessments were done at rest and with movement (after the patient completed a 90° logroll while in bed).The time to first rescue analgesic, total morphine consumption at (24 h and 48 h) and the presence of side effects, such as headache, rash, nausea, vomiting, dizziness and drowsiness were recorded. The severity of postoperative nausea and vomiting (PONV) was graded on a four-point ordinal scale (I) not at all, (II) sometimes, (III) often or most of the time, and (IV) all of the time with vomiting . OndansePatient satisfaction was measured at 24 h post-operatively using a numerical score of 1-4 .After the study was completed, randomization and allocation were revealed for data analysis.Sample size estimation was made based on morphine consumption in a retrospective sample of 50 patients who was undergoing spinal surgery in our department. The sample size was calculated using power analysis  to detect 50% difference in morphine consumption between groups at 48 h post-surgery and was found to require at least 24 patients per group. Thus, we decided to include 30 patients per group to allow for possible drop-out.p-value of less than 0.05 was considered significance.Data were presented as median (with inter-quartile range) or mean ± standard deviation. While qualitative data were presented as number (frequency distribution). Data such as ASA grade, sex distribution, Patient’s satisfaction, and Side effects were inferred by Chi-square test and fisher’s exact test. Data such as age, weight, height, mean duration of surgery, time of first rescue analgesic and total morphine requirement were inferred by ANOVA and post hoc Bonferroni test was used for in intergroup comparison. Differences in NRS scores were analyzed using the kruksal-wallis-test and the Mann–Whitney U-test was used for subsequent pairwise comparisons. The From November 1, 2015 to March 1, 2017, 131 consecutive patients who met the inclusion criteria were allocated for the study when compared with group D, group E and group P.There was a significant prolongation when groups E and D were compared with group P respectively with no significant difference between group E and group D Fig. .Fig. 2TiThe morphine requirement at 24 h was statistically different between the four groups.. There were significantly increased morphine requirements in the P group compared with E, D and D/E groups and significantly increased in E and D groups respectively when compared with D/E group with no significant difference between group E and group D Fig. . At 48 hWith regard to pain scores at rest all time points, the duloxetine/etoricoxib (D/E) group had significantly lower pain scores when compared to placebo group P, while when it compared to etoricoxib group E, also when compared D/E with duloxetine group D Table .Table 2PThe pain score in group E was significantly decreased at most time periods when compared to group P at 0, 2 and 4 h at rest when compared with group D. The pain score in group D was significantly decrease at 24 and 48 h compared to group P  shows significant differences between the four groups at 24 h (Table The most common adverse effect expected by patients in the study was nausea and vomiting grades III and IV. There was a significant increase in percentage of patients in group P (43.3%) when compared with group D/E (16.6%) and who reported nausea and vomiting. All complained patients responded to i.v.ondansetron. No statistically significant differences were noted between groups with regard to adverse effects Table .Table 5STo our knowledge, there have been no studies evaluating the combination of selective COX-2 inhibitors (etoricoxib) and a selective serotonin and norepinephrine reuptake inhibitor (SNRI) (duloxetine) after spine surgery. Therefore, we decided in this study to use this regimen based on the results of previous clinical trials. A number of reports have demonstrated success with either the use of etoricoxib –20, 23 oDuloxetine is a selective SNRI that is prescribed for treatment of depression and anxiety disorders . It is aIn this randomized study, despite the fact that each of the two drugs separately could not produce analgesia during movement, their combination induced significant reduction in pain score at rest and on movement over the study time points and also improved patients satisfaction at 24 h postoperatively. Although, each of the drugs separately were able to prolong the duration of first rescue to analgesia and reduce postoperative morphine consumption, the combination also remained significantly effective when compared with them. Therefore, this may accelerate the rehabilitation and reduce postoperative morbidity .The analgesic effect of antidepressants is typically seen after 7 to 14 days, therefore It’s commonly used for chronic pain . HoweverAlthough etoricoxib has been shown to have significant analgesic efficacy during pain at rest when compared to thecontrol group in our results, there was no effect on pain score on movement. These results resembled those of Rawal et al.  where thOpioids are considered the drug of choice for management of postoperative pain but it is difficult to induce an optimum analgesia without significant side effects . TherefoIn this study we evaluate the acute postoperative pain not the chronic pain examined in previous studies , 9, 37 bThe present study demonstrates that the perioperative administration of the duloxetine/etoricoxib combination reduces postoperative pain, beside the need for morphine at 24 and 48 h after lumbar spine surgery, and the opioid-related side effects more effectively than either drug alone. Duloxetine/etoricoxib combination may thus be a useful adjuvant to be used along with opioid as part of a multimodal analgesia in the acute postsurgical setting.Concerning limitations to our study, there are some to be applied. First it is not possible to prove that the combination of duloxetine and etoricoxib has more than just an additive effect because we did not make a full dose-response study nor associated ED50s. The second limitation of our study is that we evaluated a possible effect of duloxetine on acute postsurgical pain alone and not on the chronic one.


Some reports have highlighted the relationship between heart rate variability (HRV) and the degree of postoperative pain experienced. This study retrospectively examined whether differences in heart rate variability may be related to the appearance of postoperative pain in patients undergoing breast cancer surgery.n = 16) had no pain on admission to PACU, remaining pain free upon discharge (12 h after surgery); group B (n = 4) comprised patients with no pain on admission to PACU but who experienced increasing pain requiring intervention in PACU 1 h after surgery. HRV was measured immediately on admission to PACU and 2 h after surgery; this included variables of low-frequency power (LF), high-frequency power (HF), and LF/HF. There were significant differences in HF and LF/HF in group A compared with those in group B on admission to PACU : HF, group A, 35.4 ± 18.1; group B, 64.2 ± 9.5*; LF/HF group A, 2.7 ± 2.4; group B, 0.6 ± 0.2*, *p < 0.05). There was no significant difference in the Numerical rating scale (NRS) between the two groups immediately after admission to PACU. At 1 h after the surgery, NRS in Group B increased, and there were significant differences in NRS values between the two groups 1 h after surgery prior to the use of analgesic agents . Patients in group A required no analgesic agents for at least 12 h after surgery.We retrospectively analyzed 20 postoperative patients who had no pain immediately upon admission to the post-anesthesia care unit (PACU), divided into two groups: group A (Lower HF and higher LF/HF values immediately after arrival in PACU were observed in patients remaining pain free for 12 h after surgery compared to patients who experienced increasing postoperative pain 1 h after surgery. The data suggest that differences in HRV may be related to the appearance of postoperative pain. The measurement of heart rate variability (HRV) is a non-invasive method for assessing sympathetic and parasympathetic nervous system activity . SpectraSome reports have investigated the relationship between HRV and pain intensity as a predictive tool –8. JeannWe hypothesized that assessing HRV in the post-anesthesia care unit (PACU) could predict the appearance of postoperative pain in surgical patients. Until now, there have been no reports examining the relationship between changes in HRV and postoperative pain. The purpose of this study was to retrospectively examine whether differences in heart rate variability may be related to the appearance of postoperative pain in patients undergoing breast cancer surgery.The study protocols were approved by the ethics committee of the hospital (IRB405-27019). Written, informed consent was obtained from all patients prior to participation. We analyzed data from all 82 patients who underwent breast cancer surgery between 2015 and 2016  Clinical Trials Registry, UMIN registration 000023285).We selected patients who underwent breast cancer surgery because the procedures involved similar surgical time and were performed by the same surgeons, so that acute postoperative surgical pain experienced was thought to be similar in these patients.Of the 82 patients, 20 were excluded from the study because their postoperative pain scores on admission to PACU necessitated treatment with continuous low-dose remifentanil; their NRS values were above 4. Sixteen additional patients were excluded because of inadequate HRV data, due to noise from postoperative shivering interfering with HRV measurement. Patients were also excluded if they were elderly (over 70 years), had a history of cerebrovascular disease and ischemic heart disease, were treated with beta-blockers, had chronic obstructive lung disease, psychiatric illness, and/or active liver disease  or glutamine pyruvate transaminase (GPT) levels above 50 U/dL). After exclusions, 20 out of 82 patients could be analyzed. Of these 82 patients, we were able to retrospectively select 20 patients who had no pain after surgery on admission to the post-anesthesia care unit (PACU); “no pain” defined as a numerical rating scale (NRS) value between 0 and 2.n = 16) had no pain upon admission to PACU and remained pain free upon discharge from PACU (12 h after surgery); group B (n = 4) had no pain upon admission to PACU, but experienced increasing pain in PACU 1 h after surgery, requiring analgesic therapy  . All aneAnesthesiologists analyzed patients’ pain using the numeric rating scale . If the NRS was above 4, additional analgesic agents were used if patients complained of pain. Patients who required additional analgesic agents immediately after surgery upon arrival at PACU were excluded from the data analysis. In these patients, non-steroidal anti-inflammatory drugs  or continuous infusion of low-dose remifentanil (0.01–0.03 μg/kg/min) were used for analgesia. Then, we were eventually able to analyze 20 patients who had no pain immediately after surgery upon arrival at PACU (NRS between 0 and 2).n = 16) had no pain upon admission to PACU and remained pain free upon discharge from PACU (12 h after surgery); group B (n = 4) had no pain upon admission to PACU, but experienced increasing pain in PACU 1 h after surgery, requiring analgesic therapy.All 20 patients remained in PACU for at least 12 h after surgery. In such 20 patients studied, flurbiprofen axetil 50 mg was used for analgesia if postoperative pain occurred (1 h after surgery). These 20 patients (who had no pain upon admission to PACU) were divided into two groups at 1 h after the surgery. Group A  . HRV wasU testing was used for analyzing comparisons between groups. Statistical significance was set at p < 0.05. All calculations were performed on a computer running Windows 7 and Stat Mate software .All data are expressed as mean ± standard deviation (SD). Mann-Whitney Table p < 0.05). There was no significant difference in NRS between the two groups immediately after entering PACU.Table 2 between the two groups when assessing HRV in PACU.Table p < 0.01).Table Table In all 16 patients in group A, no analgesic agents were required for at least 12 h since their NRSs values were kept below 3 during the 12 h after the surgery.The present study revealed that lower HF and higher LF/HF values were observed immediately arrival in PACU in patients who had adequate analgesia for 12 h after the surgery concluded when compared to those who did not have adequate pain relief 1 h after surgery. This suggests that assessment of HRV may be related to the appearance of postoperative pain.Some reports have described a possible association between changes in HRV and pain prediction. Jeanne et al.  reportedA recent review article  showed tIn this study, HRV differed between patients who had increased postoperative pain 12 h after surgery and patients whose pain remained adequately controlled. It is unclear why HRV differed between the two groups immediately after surgery, despite there being no differences in NRS in either group at that time. Possible mechanisms for consideration include that the balance of sympathetic and parasympathetic tone (which did not affect hemodynamic changes such as heart rate or blood pressure) would be altered prior to an increase in pain intensity. Broucqsault-Dédrie et al.  reportedIn our study, lower HF values were found in patients whose postoperative pain did not increase after 12 h in PACU. This is in contrast to a previous study by Papaioannou et al.  that shoAs such, we need to identify the relationship between HRV changes and postoperative pain. In addition, the subjects in whom HRV was assessed were patients undergoing breast cancer surgery. These patients typically have little postoperative pain compared to patients undergoing abdominal surgery who would need intervention for severe pain before HRV could be assessed. We thus cannot rule out that differing results may be seen in other postoperative patient groups.There are several limitations to this study. Firstly, the number of patients assessed was small, so that further, higher powered studies are necessary to clarify whether HRV could be a clinical surrogate for postoperative pain in surgical patients. Secondly, we did not assess the course of changes in NRS and HRV across time; as such, the temporal relationship to direct alterations in NRS and HRV were not shown, because we focused on whether HRV could be a clinical surrogate predictive of postoperative pain in surgical patients who were pain free upon arrival in PACU. As such, we need to examine the relationship between alterations in NRS and HRV over time when postoperative pain increases. This study was also retrospective. A future, prospective study is recommended to help identify the relationship between HRV changes and postoperative pain. Ledowski et al.  showed pLower HF and higher LF/HF values were observed immediately after arrival in PACU in patients, who had adequate analgesia for 12 h after surgery concluded, compared to patients whose pain relief was not maintained for 1 h after surgery. This suggests that differences in HRV value may be related to the appearance of postoperative pain.


Chronic prostatitis/chronic pelvic pain syndrome is a common disorder seen in men under the age of 50 and has a considerable negative impact on quality of life; it is a complex and difficult condition to treat, owing to its wide symptomatology. In order to effectively treat this condition, the UPOINT system was developed: it allows clinical profiling of a patient’s symptoms into six broad categories  to allow individualized and multimodal therapy. In this review, we present the most recent advancements in the treatment of chronic prostatitis/chronic pelvic pain syndrome from the past few years. It has a significant negative impact on quality of life that is comparable to that of other chronic illnesses such as diabetes mellitus, Crohn’s disease, and myocardial infarction2. With a wide range of symptomatology, patients with prostatitis can present with lower urinary tract symptoms (LUTS) and genital and pelvic pain3. Perhaps much of the initial challenge in the management of these patients was understanding that the prostatitis “syndrome” consisted of multiple distinct clinical entities. In the validated classification system developed by the National Institutes of Health (NIH), prostatitis can be divided into four categories: acute bacterial prostatitis, chronic bacterial prostatitis, chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS), and asymptomatic prostatitis4. Accounting for more than 90% of urological outpatient cases seen, CP/CPPS remains one of the most common urologic disorders in men younger than 50 years old that is often poorly understood and complex to manage5. Current multimodal treatments for CP/CPPS have been previously described in recent articles. After performing a literature search of PubMed, we present in this review the most recent advancements in the treatment of CP/CPPS over the last three years.Prostatitis is a common condition, with an estimated prevalence of 2 to 9% in the general male population6. Each domain is treated differently, allowing for a multimodal approach. Multiple clinical trials have externally validated the UPOINT system, and it is gaining increasing widespread use and effectiveness2. Zhaoet al. applied the system in a study of 389 patients in China and demonstrated that the number of positive UPOINT domains correlated well with a worse NIH chronic prostatitis symptom index (CPSI) total score7. In a study of 100 patients utilizing UPOINT phenotyping, Shoskeset al. demonstrated that 84% of patients experienced a significant decrease in CPSI score at 26 weeks, defined as a six-point or greater decrease8. Similarly, Magriet al. conducted a study of 914 patients using the UPOINT system and found that 77.5% of patients experienced a similar decrease in CPSI score that was durable at 18 months9. Although further validation studies are required, such an approach provides physicians with a structured approach to an otherwise-challenging condition. For the purpose of this review, we present the latest novel treatments for the management of CP/CPPS based upon the UPOINT system.The UPOINT system is a method to clinically profile a patient’s symptoms into six broad categories to allow individualized and multimodal therapy. Briefly, the six domains include urinary symptoms, psychological dysfunction, organ-specific symptoms, infectious causes, neurologic dysfunction, and tenderness of the pelvic floor muscles2. In a randomized controlled trial, Nickelet al. reported that tamsulosin 0.4 mg daily significantly improved NIH-CPSI scores across multiple domains compared to placebo10. In another study, silodosin 4 mg was shown to reduce NIH-CPSI scores compared to placebo11. However, in a recent review published inEuropean Urology, owing to the heterogeneity of the studies, the authors could not recommend alpha-blockers as first-line monotherapy, although it may be beneficial as part of multimodal therapy12. Similarly, 5-ARIs could not be recommended as first-line hormonal therapy.There is significant heterogeneity in published data regarding the use of alpha-blockers and 5 alpha-reductase inhibitors (5-ARIs) as monotherapy. Smaller studies have suggested some clinical efficacy in the use of alpha-blockers for at least 12 weeks’ durationP <0.05), respectively13. Significant improvements were also noted in the International Prostatic Symptom Score (IPSS) voiding score and International Index of Erectile Function (IIEF) score.Studies have shown that phosphodiesterase-5 (PDE-5) inhibitors can improve LUTS by acting upon nitric oxide synthase and PDE-5 present within prostatic tissue. Park and colleagues reported that the use of mirodenafil, a newer PDE-5 inhibitor, in combination with levofloxacin versus levofloxacin alone improved the NIH-CPSI score by –7.2 and –3.2  can inhibit inflammation and pain by regulating the cyclooxygenase (COX-2) pathway2. In a trial by Zhouet al., 48 men with CP/CPPS were randomly assigned to treatment with tetracycline for 3 months versus placebo. They reported a significant decrease in the mean NIH-CPSI score by 18.5 points in the treatment group26. Nonetheless, two other randomized controlled trials investigating the efficacy of ciprofloxacin or levofloxacin for a 6-week duration compared to placebo in the treatment of CP/CPPS did not reveal any significant difference in the change of NIH-CPSI score28. As such, there is currently not enough evidence to support the use of antibiotics in the primary treatment of CP/CPPS12.Typically, patients presenting with CP/CPPS have already received multiple courses of antibiotics. However, in the absence of documented infection, the use of antibiotics in the treatment of CP/CPPS has been controversialet al. reported that men who received prednisone and levofloxacin for 2 weeks followed by levofloxacin for another 2 weeks had a statistically significant decrease in their NIH-CPSI, pain, and voiding score compared to the control group that received levofloxacin and placebo alone29. They noted also a difference in the WBC count on extra-prostatic secretions at 4 weeks and no significant adverse effects. Newer second-generation formulations aimed at decreasing systemic activity while maintaining local efficacy such as beclomethasone dipropionate have also gained increasing interest. Bozziniet al. followed 180 men with CP/CPPS who received beclomethasone dipropionate suppositories and 136 of the 180 men who also receivedSerenoa repens extract30. The authors noted that men in the steroid group versus steroid andSerenoa repens combined group had significant decreases in voiding frequency compared to baseline  and increase in uroflowmetry . Both groups also had improvement in perineal pain on visual analog scale. The authors concluded that beclomethasone dipropionate suppositories were safe and observed improvement in LUTS and pain.Corticosteroids are not currently standard of care in the treatment of CP/CPPS; however, they may play a role in multimodal therapy. In a randomized double-blind parallel study, Yang31. Kotbet al. investigated the efficacy of antifungals and urinary alkalinization with potassium citrate in 1,000 men who did not respond to 4 weeks of antibiotics and alpha-blockers31. The predominant complaint was noted to be frequency and urgency, with vague genital discomfort. Of the 1,000 men, 803 reported at least 80% improvement in their urinary and pain symptoms, defined subjectively by the patient on a scale of 1 to 10. A lower initial prostate-specific antigen (PSA) and age were found to be associated with better response to antifungals.Although the incidence of fungal prostatitis is quite rare and beyond the scope of this article, studies have shown an increasing incidence of fungal UTIs, in part owing to the prevalent usage of broad-spectrum antibiotics32. The patients had tried other therapies including antibiotics, NSAIDS, and alpha-blockers for at least 6 weeks. Exclusion criteria included an NIH-CPSI score of less than 15, chronic bacterial prostatitis based on the Meares and Stamey glass test, post-void residual greater than 100 mL, prostate cancer, or urethral strictures. The device was applied over the perineum twice a day at home for 10 minutes using a portable device provided by the manufacturer. Both the active and the placebo devices functioned and appeared identical. At 12 weeks, there was no significant difference between the SEM and placebo group in NIH-CPSI score. However, subgroup analysis showed that the benefit with SEM was more pronounced than with placebo in patients with symptom duration of less than 12 months.Neuromodulatory techniques have shown promising results in the treatment of CP/CPPS. In a randomized, placebo-controlled, double-blind trial, researchers from Switzerland investigated the effect of sono-electro-magnetic (SEM) therapy in the treatment of refractory CP/CPPS33. Its effects are hypothesized to be neuromodulatory in origin, but studies have shown that acupuncture may also increase endogenous opioid release and modulate sympathetic tone and pain pathways35. A randomized sham-controlled trial enrolled 100 patients to receive acupuncture at either seven acupoints bilaterally or sham points adjacent to these points35. A baseline NIH-CPSI score was obtained and subsequently at 6, 8, 16, and 24 weeks after treatment. At 8 weeks, 48% of patients in the treatment group experienced complete resolution of symptoms as compared to 36% of sham participants. Although both groups experienced significant reduction in NIH-CPSI scores by the end of the 24th week, the decline in scores remained significantly greater in the treatment group as compared to the sham group (P <0.001). In a recent systematic review of acupuncture for CP/CPPS by Qinet al., the authors concluded that, based on the current evidence, acupuncture is an effective treatment for CP/CPPS. When compared to sham acupuncture, real acupuncture was more effective at improving NIH-CPSI scores and subscores with a mean difference of –6.09 (95% CI: –8.12 to –5.68)36. In contrast, when comparing acupuncture to medications, no definitive conclusions could be drawn owing to the heterogeneity and risk of bias of the included trials.Although the exact mechanism of action is not fully understood, acupuncture has been used as a complementary therapeutic option in the management of refractory CP/CPPS in Eastern countries for some timeet al. performed a pooled analysis from three clinical trials of tanezumab in patients with chronic pelvic pain, including women with interstitial cystitis and men with CP/CPPS37. In total, 208 patients were randomized to placebo or tanezumab, of which there were 38 and 41 men in the two groups, respectively. Pooled analysis of the three trials showed that although tanezumab provided some improvement in pain scores, these were not statistically significant in the male CP/CPPS population. The authors concluded that tanezumab remains a promising therapy requiring further studies, especially in the CP/CPPS population.There has been recent interest in targeting key modulators in the pain pathway and nerve growth factor (NGF) inhibition, all of which have been shown to reduce pain behaviors in animal models. Tanezumab, a monoclonal antibody against NGF, is such an agent. Nickel38. In a study by Falahatkaret al., 60 men with CP/CPPS underwent transurethral intraprostatic injection of BoNT-A or normal saline in a randomized double-blind study39. Their results showed a statistically significant continuous and durable improvement in NIH-CPSI total and subscale scores at the final 6-month evaluation. Similar trends were observed in other instruments such as the AUA symptom score, visual analog scale, and quality of life scores. In contrast, in the placebo group, there was no significant change from baseline. No significant adverse events were recorded except for two patients who developed transient gross hematuria, which was managed conservatively. Given that the most prominent improvement was noted in the pain subscale, intraprostatic BoNT-A may be an option in patients with CP/CPPS and pain as a predominant symptom.Botulinum neurotoxin-A (BoNT-A) is a toxin that is familiar to many urologists and is used in a variety of urologic conditions such as neurogenic detrusor overactivity. Studies have shown that its effects when injected intraprostatically include inhibiting the release of pain mediators and prostatic gland atrophyCP/CPPS can be a challenging condition to treat, and a multimodal approach is usually required. Most of these patients have usually been on multiple courses of antibiotics without relief, leading to frustration among patients and practitioners. In addition to the current armamentarium of therapies, we present in this article a wide range of novel agents which have shown some clinical efficacy in the treatment of CP/CPPS. Many of these treatment strategies have shown promising results yet will require larger studies to demonstrate significant clinical impact.


A localized form of epidermolysis bullosa simplex (EBS-l) is considered one of the mildest forms of epidermolysis bullosa (EB), with blisters limited to the palms and soles. However, these lesions can be very painful. The aim of the study was to characterize pain in patients with EBS-l and evaluate its impact on quality of life (QoL). Patients were contacted via the Research Group of the French Society of Pediatric Dermatology and the association of EB patients (DEBRA France). One investigator used a standardized questionnaire that included validated scales for pain and QoL for a telephone interview.We included 57 patients (27 children). All patients had pain: the mean pain on a 10-mm visual analog scale was >5 for most adults (90%) and children ≥8 years old (94%) when blisters were present and for most adults (73%) and about half of the children ≥ age 8 (53%) during dressing changes. Similar results were found for younger patients. Overall, 75% of patients had neuropathic pain; for 55% of children and 73% of adults, the pain had a moderate to severe impact on QOL. Only seven patients used premedication before changing dressings and seven regularly used oral treatment for chronic pain. A total of 21% and 23% of patients used non-steroidal anti-inflammatory drugs and grade 2 analgesics, respectively. These treatments were not effective for neuropathic pain. Six patients tried 5% lidocaine plasters on their feet, with good efficacy.EBS-l patients have frequent and severe pain with neuropathic characteristics. This pain is undertreated and affects QoL. Inherited epidermolysis bullosa (EB) is a heterogeneous group of rare genodermatoses characterized by cutaneous and/or mucosal fragility resulting in post-traumatic blistering. The diseases are classified according to the level of skin cleavage. In EB simplex (EBS), the cleavage plane is within the basal keratinocytes of the epidermis . EBS is Pain is constant in EB . AlthougPatients >6 months old of both sexes with EBS-l were included between May 2015 and January 2016. They were analyzed by age 6 months to 16 years (children) and >16 years (adults). EBS was diagnosed clinically by a dermatologist of one of the French Reference or Competence Centers for cutaneous rare diseases. Immunofluorescence analysis of skin biopsy and/or molecular analysis were not necessary for inclusion. Patients were contacted by the Research Group of the French Society of Pediatric Dermatology, the EB patient association (DEBRA France) and social networks of DEBRA France.After telephoning patients about the study, information and consent notes were sent by e-mail. After obtaining written consent, a standardized questionnaire was sent by e-mail to patients and/or their parents before telephone interviews, to familiarize them with it, then patients were interviewed by telephone by one investigator (JB). The questionnaire included scales to evaluate pain and quality of life (QoL). An estimated level of EB-related pain was assessed in adults and in children aged 8 and over using a linear visual analog scale (VAS) , rangingThe Pain Questionnaire of Saint Antoine (QDSA)  was usedThe neuropathic pain diagnostic questionnaire (DN4 questionnaire)  can confThe Hospital Anxiety and Depression (HAD) scale  was usedQoL was assessed by the Children’s Dermatology Life Quality Index (cDLQI)  for chilThe QOLEB is a specific scale developed for EB patients. It consists of 17 individual items which were scored from 0 to 3 in the order of least to most impact. The questions broadly fell into two dimensional constructs: ‘functioning’  and ‘emotions’. The total score range from 0 (absence of impact on QoL) to 51 (major impact on QoL).This study has been considered as a non-interventional observational study, and then no ethics committee approval was necessary..We included 57 patients . The mean age for the 27 children was 8.5 ± 4.6 years (range 21 months to 16 years) and for the 30 adults 38.4 ± 16.2 years (range 17–85 years). Nine patients had de novo EBS-l. As expected, patients declared to have blisters localized to palm and soles without involvement of nails, mouth, eyes and nutritional compromise. The mean age at the beginning of blisters was 11.4 months (range birth to 20 years). Blistering was preferentially localized to palms and soles All patients declared having pain. Pain was localized to feet (100%) and hands (39%) and was usually associated with the formation of blisters and care. Five patients had pain even without blisters. Pain occurred before (10%), during (51%) or after (39%) the onset of blisters. As expected, it was triggered by friction (100%), walking (95%), heat (42%), trauma (39%) and hyperhidrosis (33%). Summer was the worst season, with 79% of patients experiencing constant or frequent pain and 56% unable to walk more than 1 km because of pain, as compared with 40% and 21%, respectively, during the winter.For daily pain, 24% of children ≥8 years old and 20% of adults reported a mean cutaneous pain >5 on the VAS, and 50% of children ≤7 years old a pain ≥4 by the FLACC and FPS.The formation of blisters and erosions secondary to blisters was painful, even at a distance from care. For 90% of adults and 94% of children ≥8 years old, the mean cutaneous pain was >5 on the VAS. The mean pain intensity was 7 ± 1.7 and 6.9 ± 1.9, respectively. For 80% of children ≤7 years old, the mean cutaneous pain was ≥4 and the mean pain intensity 6.8 ± 2.7 by the FLACC and FPS  had neuropathic pain according to the DN4 questionnaire, with a total score ≥ 3. This pain was described as “burning” (88%), “pricking” (67%), “electric shocks” (33%),“tingling” (44%), “numbness” (37%) and “itching” (86%)  were covered. As well, only 10% (4 adults and 2 children) were considered disabled.http://context.reverso.net/traduction/anglais-francais/care+protocol+has) been established for only 11 children (41%).In all, 22 adults had a job, 4 were disabled workers, 5 were students and 3 were housewives; 35% had occasional work stoppage because of their pain and 2 patients had to change their work because of pain. Overall, 87% of children were absent from school because of pain: once a week (6%), once or twice a month (13%), 5 to 10 absences a year (39%) and fewer than 4 absences a year (29%). A patient had to quit school because of too frequent absenteeism and psychological impact. A protocol for care at school had  had a regular follow-up by a psychologist because of the disease. According to the HAD, 11% of patients (2 children and 4 adults) were considered to have anxiety because of the disease and 4% of adults had depression.Only 7 patients had a specific follow-up by an algologist, all in a French Reference Center. Only 7 used analgesics before changing the dressing: 5 used the eutectic mixture of local anaesthetics (EMLA®) applied on blisters 1 h before a dressing change and 2 children used tramadol Table . For paiOnly 26% of patients (9 adults and 6 children) wore specific shoes particular, in particular shoes with a silicone sole. Only eight patients (3 children and 5 adults) were followed by a podologist; 13% were followed by paramedical professionals (physiotherapist or osteopath) for back pain secondary to bad position when walking. In all, 9% of patients (1 child and 4 adults) were practicing breathing techniques or relaxation techniques and 2 patients attended medical spas. Four patients used alternative medicine. 30% of children used distraction (tablet or video games) to ameliorate the pain during dressing changes.EBS-l is usually considered one of the mildest subtypes of EB. However, most of our patients with EBS-l had frequent and severe pain during blister flares and dressing changes. We found only one article on this topic, by Fine et al. , who repAnalysis of pain characteristics by the DN4 questionnaire showed that 75% of patients had neuropathic pain. Furthermore, 93% of patients had pruritus during the healing of blisters, a frequent symptom associated with neuropathic pain, and 49% of patients experienced night waking. Neuropathic pain is frequent in EB patients, independent of the subtype, but few data on this topic are available. –16 IndeeNo specific data are available on QoL in patients with EBS-l. Fine et al.  analyzedThe questionnaire QOLEB  is the fConsistent with the impact of EBS-l on QoL, patients had also socioprofessional difficulties. Overall, 35% of our adults had occasional work stoppage due to their pain, two patients had to change their work because of pain and 87% of children were absent from school because of pain. However, only 4/30 adults were considered disabled workers and 11% of children had a specific protocol for pain and care at school. Furthermore, only 48% of patients were totally covered by the health insurance system. These results can be explained by the misinformation of patients themselves and their physicians, an underestimation of their symptoms and a misunderstanding of the disease by social professionals. Thus, follow-up by social assistance staff, possibly in a specialized center, seems essential.Recently, the best clinical practice guidelines for pain in EB  were pubPsychological therapies  for pain management have been shown to modify pain intensity, reduce related distress, decrease pain-related functional disability and improve coping with pain . In our Finally, only a few patients used specific treatment for neuropathic pain. Six patients used 5% lidocaine plasters in this indication, with good efficiency and no side effects. Lidocaine exerts its action by blocking the abnormal sodium channels present in higher number on hyperactive or damaged nociceptors that transmit pain. To our knowledge, this is the first report of the efficiency of a local analgesic in this indication. Further controlled studies are necessary to demonstrate the interest of 5% lidocaine plasters in this indication, because topical treatment for a localized disease is attractive.Botulinum toxin injections were reported to be efficient in EBS-l patients in a case series : 13 pati. A close collaboration between the dermatologist and algologist is essential to evaluate and manage pain.We found that EBS-l patients have frequent and severe pain during blister flares and dressing changes and that this pain has neuropathic characteristics. This pain is undertreated but has an impact on QoL and socioprofessional activities. A better knowledge of the specificities of pain in EBS-l is essential for diagnosis and adapted treatment, with the development of new strategies including topical analgesic treatments such as lidocaine patch