The incidences of herpes zoster (HZ) and postherpetic neuralgia (PHN) are significantly influenced by age. As individuals age, the occurrence of spinal disorders increases, thereby raising the likelihood of HZ and PHN coexistence. Considering this, our study aimed to explore the potential impact of pre-existing spinal disorders at the nerve level where HZ developed, on the severity of zoster-associated pain (ZAP) and the incidence of PHN. For our investigation, we retrospectively analyzed a total of 237 patients who presented with HZ and ZAP at various sensory levels  with or without pre-existing spinal disorders. The presence or absence of spinal disorders at the sensory level affected by HZ was determined using computed tomography or magnetic resonance imaging. Our study results revealed that the group with spinal disorders at the sensory level where HZ developed did not exhibit an increased incidence of PHN. However, 3–6 months after HZ onset, this same group showed significantly higher ZAP scores compared to the group without spinal disorders. It implies a need for heightened pain management, as the coexistence of these conditions can increase pain severity. This study furnishes an initial standpoint to delve into intricate interactions between two diseases. Herpes zoster (HZ) is a prevalent condition characterized by a painful, unilateral, vesicular rash arising from the reactivation of a latent varicella-zoster virus (VZV) in the ganglia of the cranial nerve or dorsal root. The most noticeable feature is rash, but the most incapacitating symptom is zoster-related acute and chronic pain ,2,3.Despite not being lethal, HZ can cause zoster-associated pain (ZAP), which encompasses acute HZ pain and chronic postherpetic neuralgia (PHN). ZAP results from virus-induced damage and heightened sensitivity of affected segmental sensory neurons. The reactivated virus damages both peripheral and central nerves and triggers inflammation, immune responses, and varying degrees of neuronal loss in the affected spinal ganglia ,3. ApproPHN is associated with several risk factors, including decreased cell-mediated immunity, advanced age, female sex, presence of a prodromal phase, more severe rash, acute intense pain, insufficient nutrient intake, and psychosocial risk factors ,7. The iThe increasing age of the global population is expected to result in a significant increase in the incidence of spinal disorders in the coming decades, thereby posing a substantial global health challenge . With inWe hypothesized that the coexistence of HZ and spinal disorders at the same nerve root level, as well as the synergistic increase in pain, could also have an impact on the development of PHN since severe pain at the onset of HZ is considered one of the major factors leading to its development. To our knowledge, no studies have investigated the relationship between these two conditions and their potential impact on prognosis, particularly regarding the possible exacerbation of symptoms. Therefore, we examined whether ZAP increases due to a pre-existing spinal disorder and whether the probability of PHN increases thereafter.This study was a retrospective comparative review of chart data, ensuring the preservation of patient privacy and data confidentiality throughout the research process. The institutional review board centers of Ewha Womans University Seoul Hospital (SEUMC 2023-02-014) and Ewha Womans University Mokdong Hospital (EUMC 2023-03-041) approved the study. Due to the absence of direct contact with the study population and the removal of all patient identifiers from the dataset during initial collection, the requirement for written informed consent was waived.We included 237 patients with ZAP who received medical treatment at the outpatient pain centers of the Ewha Womans University Seoul Hospital and Mokdong Hospital between 2019 and 2022. Electronic clinical records and survey responses were retrospectively reviewed to confirm adherence to inclusion criteria.The inclusion criteria were as follows: (1) HZ at the cervical, thoracic, lumbar, or sacral sensory level; (2) ZAP scores ≥4  scores); (3) patients within one month of HZ infection; (4) patients who had undergone magnetic resonance imaging (MRI) or computed tomography (CT) with images that could determine the presence or absence of a spinal disorder; and (5) patients aged ≥18 years.The exclusion criteria were as follows: (1) patients who had already been diagnosed with HZ in the past several years; (2) patients with no symptoms, even if a spinal disorder was discovered during the imaging examination; (3) patients who received radiofrequency ablation for pain relief related to ZAP or underwent invasive interventional treatments, including surgery, vertebroplasty, or kyphoplasty for pain relief related to spinal disorders; and (4) patients who had diagnostic codes for cancer, human immunodeficiency virus infection, organ transplants, chronic obstructive pulmonary disease, rheumatic diseases, and autoimmune diseases, which are considered potential confounders of HZ and PHN as the patient may be immunosuppressed as a consequence of these conditions or their treatments ,12,13,14While other invasive therapeutic interventions were excluded from this study, selective nerve root blocks (SNRB) were included as a commonly performed therapeutic intervention for both ZAP and pain associated with spinal disorders ,15,16.SNRB procedures were performed under fluoroscopic guidance, with the patients placed in a prone position for thoracic and lumbosacral procedures. Following standard sterile preparation, the fluoroscope was rotated obliquely to visualize the space between the nerve root to be treated and the pedicle on the ipsilateral side. The needle was carefully advanced next to the nerve root and placed slightly inferior to the pedicle. In the lateral image, the final position of the needle was observed just anterior to the zygapophyseal joint, whereas, in the anterior–posterior (AP) view, it was observed just inferior to the pedicle. After ensuring no vascular or epidural uptake, 2 mL of 0.2% ropivacaine containing 5 mg dexamethasone was administered.The anterolateral approach was used for the cervical procedure, and patients were placed in the supine position. The fluoroscope was angled obliquely, and a needle was advanced towards the medial side of the superior articular process, located just behind the foramen. Once the needle contacted the superior articular process, it was carefully advanced ventromedially towards the posterior section of the foramen. Before administering 1 mL of 0.2% ropivacaine and 5 mg of dexamethasone, negative vascular and epidural uptake was confirmed using a contrast medium. All procedures were performed by skilled pain physicians.The evaluation period was defined as a range of 1–6 months after HZ onset. Numerous research studies have defined clinically significant PHN as persistent pain, with an intensity of ≥3 points on the NRS ,17,18. AThis study included representative spinal disorders associated with degenerative etiologies ,19,20,21The primary outcome measure for this study was the NRS score for ZAP, which was evaluated at 1–6 months following the onset of HZ. The secondary outcomes included the incidence of PHN, medication dosages, and medication discontinuation rates. The study examined the PHN rate among patients who had ZAP and the entire patient group, which included those who had recovered. If any other anticonvulsants were used, they would need to be explicitly stated. However, in this study, there were no patients who received anticonvulsants other than gabapentin and pregabalin. Therefore, all anticonvulsant doses were converted to the equivalent dose of pregabalin ,23 and ot-test was used to compare the outcomes between the 2 groups for continuous variables, whereas the Chi-square test or Fisher’s exact test was used for categorical variables. At each time point, the NRS scores were compared using repeated-measures analysis of variance (ANOVA) with Bonferroni correction for post hoc comparisons. The discontinuation rate of drugs was assessed by the Kaplan–Meier survival method and differences between both groups were compared using the log-rank test. SPSS version 23.0  was used for statistical analysis, and a p value < 0.05 was considered statistically significant.Continuous variable normality was examined using the Shapiro–Wilk test. The continuous variables were presented as mean ± standard deviation or median (interquartile range), while categorical variables were expressed as numbers (percent). The Mann–Whitney U test or independent During the study period, 237 patients were enrolled, of whom 234 satisfied all inclusion criteria, and 3 were disqualified due to exclusion criteria. The patients who reached an NRS score of zero and no longer required conservative treatment were considered to have achieved complete recovery. Ultimately, the non-spinal disorder group included 133 patients, and the spinal disorder group included 101 patients . Table 1The types of spinal disorders included spinal stenosis, herniated nucleus pulposus, compression fracture, and spondylosis .p < 0.05; Both groups demonstrated significant changes in NRS scores over time compared to baseline values. The NRS values were higher in the spinal disorder group at 3–6 months than in the non-spinal disorder group ” by acknowledging its similarity to the etiology of PHN following HZ. Second, we posited that the presence of spinal disorders might result in reduced physical activity, contributing to higher average pain intensity 3–6 months after HZ onset. Although the presence of spinal disorders may not directly influence the incidence of PHN, it seemed to play a role in impacting the overall pain experience following the occurrence of HZ.DCS is a condition in which multiple nerves are compressed at two or more sites, causing symptoms at the same nerve pathway that may exhibit a synergistic effect ,26,27. APHN is a noteworthy clinical problem that can last for several years and has an adverse impact on the patient’s quality of life in all four health domains—physical, psychological, functional, and social ,8,38. DeIndividuals aged ≥60 years have a higher risk of developing HZ and PHN, with studies indicating that the incidence of PHN increases with age ,11,14. FPrevious studies have reported that physical functional impairment may impact the occurrence of PHN following HZ ,44,45,46The precise associations between spinal disorders and the incidence of HZ, as well as the severity of ZAP and the increase in PHN rates, have not been definitively established yet. In a study conducted by Alpantaki et al. , it was There are reports indicating that stimuli such as trauma and surgery can trigger the onset of HZ. Additionally, there are reports suggesting that spinal disorders themselves can induce the manifestation of HZ ,54,55,56ZAP can be mistaken for symptoms related to other neuromuscular or spinal disorders since differentiating between neuropathic pain caused by spinal disorders and PHN is difficult, particularly before shingles blisters develop ,60,61,62This study has some limitations. First, its retrospective nature might have led to variability among study participants. Nevertheless, heterogeneity was reduced by standardizing patient demographics, clinical variables, and imaging findings before treatment and at each subsequent follow-up visit. Second, while checking for spinal disorders, only the existing pain score was reviewed in the records, and precise details such as the date of diagnosis, physical functional scores at the initial visit, and type of treatment administered were not verified. In addition, despite the absence of significant differences in the initial medication dosages or pain scores during the first visit, the assessment of the patients’ spinal disorders remains inadequate due to the lack of pre-visit data on medication doses and pain levels. Third, although there may exist patients without symptoms despite having imaging findings related to spinal disorders, this study specifically targeted patients presenting with pain during their initial visit. Therefore, all patients showing imaging evidence of spinal disorders were inevitably included in the spinal disorder group.In conclusion, our study demonstrates that although the incidence of PHN was not significantly higher, the presence of spinal disorders at the same sensory level resulted in a significant increase in ZAP during the 3–6 months after HZ infection. Therefore, when both conditions coexist at the same sensory level, the pain intensity tends to be higher than when they are not present together, indicating the need for meticulous pain management. Conducted retrospectively, this study focuses on a specific ethnic group within a single country, despite having limitations such as a relatively small sample size. Nevertheless, this study demonstrates that the presence of concurrent conditions can potentially impact ZAP, suggesting a preliminary platform for exploring complex interactions between HZ and other conditions. Moving forward, large multicenter investigations will be essential to comprehend the intricate relationships among these diseases with precision.


With CRPS-associated prescriptions,  more CRPS patients were prescribed opioids  than controls . Conclusions: CRPS is difficult to treat with significant variance in suggested treatment modalities. Based on the results of our study, there is a divergence between some published recommendations and actual practice.Objective: The objective of this study was to evaluate discrepancies in prescription trends for analgesic medications in complex regional pain syndrome (CRPS) patients based on recommendations in the literature. Design: We conducted a retrospective case–control study. Subjects: A total of 2510 CRPS patients and 2510 demographic-matched controls participated in this study. Methods: The SlicerDicer feature in Epic was used to find patients diagnosed with CRPS I or II between January 2010 and November 2022. An equal number of age-, gender-, and race-matched controls without a CRPS diagnosis were retracted from Epic. General and CRPS-associated prescription frequencies for the following classes were retrieved for both cases and controls: benzodiazepines, bisphosphonates, calcitonin, capsaicin, neuropathic pain medications, NSAIDs, opioids, and steroids. Results: A total of 740 (29%) CRPS patients and 425 (17%) controls were prescribed benzodiazepines (95% CI 0.1–0.15), 154 (6.1%) CRPS patients and 52 (2.1%) controls were prescribed capsaicin (95% CI 0.03–0.05), 1837 (73%) CRPS patients and 927 (37%) controls were prescribed neuropathic pain medications (95% CI 0.05–0.34), 1769 (70%) CRPS patients and 1217 (48%) controls were prescribed opioids (95% CI 0.19–0.25), 1095 (44%) CRPS patients and 1217 (48%) controls were prescribed steroids (95% CI 0.08–0.14), and 1638 (65%) CRPS patients and 1765 (70%) controls were prescribed NSAIDs (95% CI −0.08–0.02),  Complex regional pain syndrome (CRPS) is a rare and painful neurologic condition often resulting from trauma with two subtypes, CRPS I  and CRPS II , which differ by the lack of or presence of a major nerve injury, respectively . CRPS isG-protein coupled receptors (GPCRs) may play a significant role in the development of neurogenic inflammation, sensitization of nociceptors, and modulation of pain signaling pathways ,5, whichIn a clinical setting, certain medications have been shown to be effective. Neuropathic pain medications, primarily gabapentin and amitriptyline, have some evidence for efficacy in pain reduction ,13,14,15The objective of this study was to evaluate the prescription trends for analgesic medications in CRPS patients and compare them to non-CRPS controls at our institution. The selected drug classes for this study have either shown symptom relief for CRPS patients ,21,25,26This study is a retrospective case–control performed using the electronic medical record (EMR), specifically the SlicerDicer feature in the Epic, to find patients diagnosed with CRPS I or II between January 2010 and November 2022 at an urban academic teaching hospital. SlicerDicer is a cohort-query tool that allows users to look at general trends in various categories related to patient care at any institution using Epic as its EMR. The following search criteria were used to locate patients via diagnosis or medical history: ‘complex regional pain syndrome I, unspecified,’ ‘complex regional pain syndrome of upper limb,’ complex regional pain syndrome, type II,’ ‘complex regional pain syndrome of lower limb,’ and ‘complex regional pain syndrome of hand.’ These were all the possible different CRPS diagnoses found in our institution’s EMR. The search yielded 2510 CRPS patient cases within this time frame.In collaboration with medical informatics, the medical record numbers (MRNs) and demographic data were retrieved for the 2510 CRPS cases. An equal number (2510) of age-, gender-, and race-matched controls for each individual subject in the case category without a CRPS diagnosis were supplied.Medication data for prescriptions between January 2010 and November 2022 were evaluated for the 5020 cases and controls. The medication classes chosen were based on published recommendations for CRPS patients as well as some medications that may be prescribed for those with chronic pain ,22,23,24Specific medications belonging to each medication class were retrieved. For each subject, the first and last prescribed dates and dosages of each medication were obtained to assess the changes in dosage over time. The years that each medication was prescribed were also retrieved in order to assess longevity of use.The first goal was to evaluate for a difference in prescription rates via drug class and specific medications between cases and matched controls. In addition to general prescription rates, a filter was applied to search for medications with a CRPS-associated diagnosis in Epic. Those cases were then compared to their corresponding controls. The second goal was to compare the longevity of medication use between the two groups. The third goal was to evaluate for change in dosage between the first and last prescription of each opioid in the CRPS group. The fourth goal was to examine prescription rates of opioids before and after 1 January 2017 to account for the release of the 2016 CDC guidelines for prescribing opioids for chronic pain .p < 0.05.For statistical analysis, a two-sample test for equality of proportions was run with a 95% confidence interval and a false discovery rate for multiple testing in order to determine a statistically significant difference between medication prescriptions in cases and controls and differences in prescriptions from prior to and after 2017. A Welch two-sample t-test with a 95% confidence interval and false discovery rate correction for multiple testing was performed to evaluate average longevity of use and statistical differences between cases and controls. A Wilcoxon rank sum test and a Pearson’s chi-squared test were run to evaluate demographic data. Significant results were considered at This study consisted of 2510 CRPS cases and 2510 age-, gender-, and race-matched controls. The median age of subjects in both the case and control groups was 58, with a range from 47 to 66. Subjects were further subdivided into age categories, with the majority of cases and controls (N = 1408 per group (56%)) between 41 and 64 years old. A total of 725 (29%) in both groups were over 65 years old, 365 (15%) in both groups were between 19 and 40 years old, and 12 (0.5%) in both groups were under 18 years old. In each group, there were 1576 females (63%) and 934 males (37%). Both the cases and controls consisted of the following races in each group: Caucasian 1538 (61%), African American 701 (28%), ‘other’ 35 (1.4%), and ‘unknown’ 236 (9.4%). ‘American Indian/Alaska native,’ ‘Asian,’ ‘multiracial’ and ‘Native Hawaiian/Pacific Islander’ were grouped together into the ‘other’ category due to the small percentage of each of these races in this study. Anyone who declined to answer or put unknown as their race was grouped into the ‘unknown’ category. These results are in p < 0.001 for all) of the following drug classes for CRPS patients: benzodiazepines, capsaicin, neuropathic pain medications, opioids, and steroids. More specifically, in the 12-year study period, 740 (29%) CRPS patients and 425 (17%) controls were prescribed benzodiazepines (95% CI 0.1–0.15), 154 (6.1%) CRPS patients and 52 (2.1%) controls were prescribed capsaicin (95% CI 0.03–0.05), 1837 (73%) CRPS patients and 927 (37%) controls were prescribed neuropathic pain medications (95% CI 0.05–0.34), 1769 (70%) CRPS patients and 1217 (48%) controls were prescribed opioids (95% CI 0.19–0.25), and 1095 (44%) CRPS patients and 1217 (48%) controls were prescribed steroids (95% CI 0.08–0.14). There was a statistically significant difference (p < 0.001) in NSAID prescriptions; 1638 (65%) CRPS patients and 1765 (70%) controls were prescribed NSAIDs (95% CI −0.08–0.02). No significant differences were found in bisphosphonate and calcitonin prescriptions between the two groups. Additionally, 2211 (88%) CRPS patients and 2510 (100%) controls were prescribed at least one of these drug classes (p < 0.001).Comparisons between the number of subjects prescribed for each type of drug class can be found in p < 0.001) CRPS patients were prescribed opioids  than were controls . More  CRPS patients  were also prescribed neuropathic pain medications than the control group . Bisphosphonates , NSAIDs , steroids , and capsaicin  were all prescribed at significantly lower rates in the CRPS group than in the control group. No significant differences were noted in benzodiazepine or calcitonin prescriptions between the two groups.A filter was applied to search for medications specifically associated with a CRPS diagnosis in Epic. A total of 670 of the cases had associated CRPS medications. They were compared with 670 controls. As shown in p < 0.001), bisphosphonates , capsaicin , neuropathic pain medications , NSAIDs , opioids , and steroids .Differences in the longevity of use of each drug class between cases and controls were assessed. p value, but, when evaluating the false discovery rate correction for multiple testing, there is no significant difference between the first and last prescribed doses.For the CRPS group only, the first and last doses of prescribed opioids were compared to assess for changes in dosage over time . A totalp < 0.001). In the control group, opioid prescriptions decreased from 905 (51%) before 2017 to 427 (30%) after 2017 . The results are listed in For both cases and controls, we examined differences in prescription rates of opioids from before and after 1 January 2017 to assess the impact of the 2016 CDC guidelines for prescribing opioids for chronic pain . Opioid There are 2510 CRPS cases and 2510 controls with no significant difference in demographics. Each control was matched in age, gender, and race. As shown in Our results show that there is a high prevalence of opioid prescriptions in the CRPS population, which is surprising since opioids are not generally recommended for this syndrome ,31. OnlyGiven the high rates of opioid prescriptions in both the case and control groups, we explored the role of the 2016 CDC guidelines on opioid prescription rates . Total pBenzodiazepines are another drug class commonly prescribed for chronic pain despite no supporting evidence . In patiNSAIDs are often used for prophylaxis and rescue in some CRPS patients despite minimal evidence . One RCTNeuropathic pain medications consist mostly of anti-depressants and anticonvulsants with limited evidence for use in CRPS . Our stuInterestingly, very few CRPS patients were prescribed bisphosphonates or calcitonin despite recommendations in the literature ,22,23,40Capsaicin is helpful in some conditions resulting in neuropathic pain but has been less studied in CRPS, possibly due to the severe burning symptoms that result from this topical medication ,45,46. OSupporting evidence for the use of glucocorticoids in CRPS is weak and long-term toxicities outweigh potential benefits . There aThere are several limitations to this study. It was difficult to ensure that CRPS was properly diagnosed with Budapest criteria  because CRPS is difficult to treat with significant variance in the suggested treatment modalities. Based on the results of our study, there is a deviation from recommendations in the existing literature to the medication prescriptions seen in actual practice. These discrepancies are likely multifactorial. Our study highlights the clinical lack of consensus and awareness on current practice evidence for this condition, while other ongoing research continues to address our incomplete understanding of the pain and inflammatory pathways associated with CRPS.


The only reported adverse event was mild local swelling in one child. Conclusions: the IACI could represent a safe and effective intervention for painful hip dislocation, both before and after surgery, with a long-lasting benefit which seems to increase as multiple IACIs are performed.Background: Hip dislocation is a common source of pain in children with neurologic impairment. When medical interventions fail, orthopedic surgery does not guarantee a definitive result as the displacement may continue postoperatively and a second operation is often required. Methods: Retrospective analysis of data regarding the safety and effectiveness of an intra-articular corticosteroid injection (IACI) in 11 patients, aged 15 ± 5 years old, collected through a telephonic questionnaire administered to parents. Results: 21 IACIs were performed, a mean number of 1.9 ± 1.5 times for each patient, at a mean age (of the first IACI) of 13.5 ± 5 years. According to the parents, the IACI significantly lowered the number of participants experiencing pain (82% reduction) and using analgesics (60% reduction). There was also a significant improvement in the children’s hip mobility (63% reduction in patients experiencing stiffness), decubitus (90% reduction in obligated positioning), behavior (80% reduction in lamenting or crying patients), sleep quality (87.5% reduction in patients awakening every night), and caregivers’ quality of life (91% reduction in worried parents). The mean reported duration of the IACIs’ benefit was 5.4 ± 2.4 months (range 1–9), with a positive correlation with the number of IACIs (r = 0.48;  Children with neurologic impairment from several causes, such as genetic syndromes, neurodegenerative disorders, traumatic brain injury, epileptic syndromes, and cerebral palsy  and the condition’s related morbidities are the most common source of pain. In fact, apart from common problems , these children often suffer from gastrointestinal (GI) disorders , neuromuscular and/or neurogenic disorders , caries, renal and/or gallbladder stones, and orthopedic conditions .Among the latter, which include osteopenia and osteoporosis, fractures, and scoliosis, hip displacement (HD) is the second most frequent deformity after equinus deformity of the foot . In partAt birth, children with neurologic impairment mostly present normal hip anatomy. In those affected, lateral displacement of the femoral head from the acetabulum usually progresses slowly, leading to hip subluxation and eventually dislocation. However, the exact pathogenetic mechanism of this process is not clear. Historically, HD has been considered the result of the altered tone of the muscles around the hip joint and, in particular, the spasticity in the hip adductors and flexors . RecentlClinically, HD may be identified through reduced hip mobility, pelvic obliquity, scoliosis, sitting imbalance, and/or pain at hip mobilization, which usually accompany loss of sitting and walking tolerance, difficulty with dressing and bathing, and sleep disturbance . DiagnosThe current optimal management for neurologic HD is based on hip surveillance programs , which uDifferent strategies are currently adopted when the hips become painful, including postural management, medical interventions, and, eventually, orthopedic surgery. Twenty-four-hour postural management and the implementation of adequate supportive equipment, with an early involvement of orthopedic services, may be of help in terms of general comfort and spasticity control . MedicalWhile an intra-articular corticosteroid injection (IACI) is a standard of care in inflammatory disorders, such as juvenile idiopathic arthritis (JIA), and inflammatory-degenerative processes, such as osteoarthritis , limitedTo our knowledge, so far only one retrospective study  has inveThe aim of the present study was to assess the safety and effectiveness of the IACI in the setting of neurologic HD in terms of pain control and improvement to patients’ and caregivers’ quality of life.We retrospectively reviewed data on patients with neurologic impairment and painful HD who received at least one IACI in the Pediatric Orthopedics and Traumatology Unit of our Institute from January 2018 to March 2023. Inclusion criteria were (1) a diagnosis of neurologic impairment from any cause, (2) painful HD of any grade (MP > 30%), and (3) having received at least one IACI to treat hip pain. Patients receiving hip surgery or other procedures for hip pain  in the 3 months preceding the IACI were excluded. Demographic and clinical data and information regarding the IACI’s effectiveness and safety were collected in an anonymized database through a Likert scale-based telephonic questionnaire administered to parents. In particular, the questionnaire was built to investigate the IACI’s effectiveness in terms of the following: use, type and frequency of medical and non-medical therapies for pain; presence, frequency and intensity of pain episodes; changes in hip mobility; decubitus; behavior; sleep quality and appetite; number of emergency department admissions for pain; and changes in caregivers’ quality of life. The IACI’s safety was assessed through local adverse events, such as swelling, bruising, erythema, depigmentation, skin atrophy, or any systemic adverse event including Cushingoid habitus, an acne-like rash, and sleep disorders.At our Institute, an IACI is performed by a pediatric orthopedic surgeon while procedural sedation is obtained with intravenous ketamine by a pediatrician with specific expertise . The multidisciplinary team includes a radiologic technologist to provide fluoroscopic guidance .Indication to give an IACI is provided on a case-by-case basis, and repeated in the same patient as needed, based on the recurrence of chronic pain. We based this approach on the model of IACI in juvenile arthritis, which can be repeated. The pediatric orthopedic surgeon and the pediatrician jointly decide to repeat the injection when the following criteria are met: other causes of pain are ruled out; there are convincing symptoms; the patient is not responding to oral treatment; and a physical evaluation clearly points at a hip related relapse of pain.Both sterile methylprednisolone acetate 40 mg/mL and 1% mepivacaine solution for injection are prepared and handled in accordance with the manufacturer’s recommendations. The patient lies supine in a neutral position with extended legs, with his/her caregiver standing nearby in order to reduce anxiety. As the appropriate level of sedation is reached, the caregiver leaves the room, and the procedure starts as a sterile aseptic technique. Skin is disinfected with chlorhexidine solution. A 22G needle is inserted under fluoroscopic guidance through the anterior capsule of the hip joint. Then 3 mL of 1% mepivacaine are injected, followed by 1 mL (40 mg) of methylprednisolone acetate solution . The needle is then withdrawn, hemostasis ensured, and a dressing is put over the injection site. Finally, the patient is monitored until awake.t-test or Mann-Whitney’s test, after checking for distribution normality through Shapiro-Wilk’s test. Correlation between parameters was investigated through Pearson’s or Spearman’s correlation tests, depending on the appropriateness for the data. Differences were considered significant for p-value < 0.05. Statistical analysis was performed using SPSS software version 26.0 (IBM). A power analysis was conducted using G*Power version 3.1 for sample size estimation, based on data from the only previous study on the topic [Continuous data were presented as mean and standard deviation. Categorical variables were expressed as numbers and percentage, and compared using Fisher’s exact test. Numerical variables were compared using Student’s he topic . The effDuring the study period, 11 patients were treated. All families could be contacted and agreed to participate in the data collection.We included 11 patients, 6 males and 5 females, aged between 3 and 23 years old (mean 15 ± 5), with neurologic impairment as a consequence of genetic syndromes , cerebral palsy , or metabolic syndromes ; the most common comorbidity was epilepsy . Their daily therapies included anticonvulsants , proton-pump inhibitors , analgesics , laxatives , and bisphosphonates . All the participants were classified into GMFCS level V and presented hip dislocation (Reimers’ migration index > 80%), with such grade of migration that a painful conflict between the femur head and the acetabulum was still recognizable. Nine patients (82%) had already received orthopedic surgery at the time of the first IACI, such as vertebral arthrodesis , proximal femur osteotomy , and adductor lengthening or tenotomy . Three participants (27%) had received painful hip-related surgical procedures  an average of 8.7 ± 4.4 years before the first IACI. None received surgery or other painful HD-related procedures during the study period. The mean age at hip pain onset was 10 ± 5 years (range 3–19).Overall, 21 IACIs were performed, as fluoroscopic-guided arthrocentesis and injection of methylprednisolone acetate 40 mg plus 3 mL of 1% mepivacaine, under procedural sedation with intravenous ketamine. All of the IACIs were performed at our Institute.Six patients received only one IACI, three received two, only one received three and another received six IACIs, resulting in a mean of 1.9 ± 1.5 IACIs for each patient. The mean age at first IACI was 13.5 ± 5 years (range 3.4–20). The follow up time from the first IACI varied between 5 and 45 months (mean 27 ± 17). The results regarding the effectiveness of each patient’s first IACI in our cohort are shown in An IACI significantly lowered the number of patients using analgesics (60% reduction), especially paracetamol, the most used, with reduced frequencies  and a five-fold increase in the rate of response to these drugs. As expected, no differences were found regarding physiotherapy, which all participants continued receiving as part of their therapeutic schedule. According to the parents, an IACI significantly reduced the number of patients experiencing pain (82% reduction), with decreased pain frequency and intensity for one of the two remaining “non-responders”. Of note, the only child who did not experience any benefit suffered from recurrent episodes of hip dislocation, which his parents had learned to reduce at home. Moreover, significant improvements in the patients’ hip mobility (63% reduction in patients experiencing stiffness), decubitus (90% reduction in obligated positioning), behavior (80% reduction in lamenting or crying patients), and sleep quality (87.5% reduction in patients awakening at least once a night) were reported. Caregivers’ quality of life significantly improved as well, with a 91% reduction in the number of worried parents needing prolonged time caring for their children.We therefore compared the first IACI’s effectiveness in the three patients who had already undergone hip surgery to the eight who had not. Results of this analysis are shown in Both subgroups showed positive results, confirming the reduction in analgesic use and pain episodes, and the improvement in patients’ and caregivers’ quality of life, as observed in the entire cohort. Remarkably, no significant differences were found in the rate of improvement after the first IACI when comparing preoperative and postoperative patients.p-value = 0.04). Moreover, we found a negative correlation between age at first injection and benefit duration . After dividing the population into two age groups, the benefit duration of the first IACI was significantly higher in those younger than 14 years compared to those who were older . No significant differences in benefit duration were shown when comparing patients who had already received hip surgery to those who had not .Overall, the mean reported duration of the IACIs’ benefit was 5.4 ± 2.4 months (range 1–9). Mann-Whitney’s test revealed a positive correlation between the number of IACIs and the benefit duration  developed mild local swelling for two days. No other local or systemic adverse events were reported.Several studies have shown how hip surveillance programs improve the outcome of HD in terms of rate of dislocated hips and salvage surgery ,34,35. HTo our knowledge, only one previous retrospective study  evaluateOur study confirms that the IACI is an effective and safe procedure in neurologic HD, with a significant rate of resolution of pain, reduction in analgesic use, and improvement of both patients’ and caregivers’ quality of life. These effects lasted on average more than five months in our cohort. Interestingly, our results suggest that the procedure may be repeated as needed in order to obtain progressively more extended periods of wellness. The benefit seems to last longer when the IACI is performed in younger children. No significant differences were found when comparing preoperative and postoperative patients.Even when the total number of injections was small, no relevant adverse events were reported in our cohort, including those typically associated with IACIs, such as joint erythema, bruising, skin or subcutaneous atrophy, and depigmentation . These rAccording to the American College of Rheumatology, an IACI is the first-line therapy for adults with rheumatoid arthritis or hip osteoarthritis, and children with oligoarticular JIA . AlthougThe most commonly used drugs for IACIs in JIA include methylprednisolone acetate (MPA), triamcinolone acetonide (TA), and triamcinolone hexacetonide (TH). While in vitro studies suggest lower chondrotoxicity for MPA (with betamethasone being the most toxic) , TH has Taking into account the widely positive results concerning the IACI’s effectiveness, the main strengths of our study are the wide age range of our cohort, the inclusion of patients who had already received hip surgery , the absence of relevant local or systemic adverse events, and the prolonged study period, with an average follow up time of more than 2 years (and a maximum of approximately 4 years) from the first IACI.The primary study’s limits are the retrospective design, the small sample size with different etiologies, a potential recall bias, and the lack of specific pain scales, leading to a reliance on the parents’ judgement. However, the literature suggests that these children’s parents are to be considered reliable in estimating their pain . MoreoveFinally, we believe that these data significantly add to the limited available evidence, allowing physicians to consider this option in a pragmatic and palliative perspective. Future randomized controlled trials, including the need for a sham sedation procedure, are needed to definitively confirm these results and clarify factors predictive of the benefit, size, duration, long-term effectiveness and adverse events.This study is further confirmation of the possible role of IACIs in treating painful hip dislocation in children and young adults with neurologic impairment, showing a significant rate of resolution of pain, reduction in analgesic use, and improvement of both patients’ and caregivers’ quality of life. The IACI can be performed both before and after surgery, with the expectation of similar benefits. Younger children seem to benefit for longer from this procedure. Even if symptoms can be expected to recur or slowly progress, the IACI may be considered a test to determine which patients may benefit the most from surgical reconstruction or, in some cases, avoid surgery. No relevant local or systemic adverse events were reported in our cohort. We believe our data support the role of the IACI as a possible bridge for reconstruction surgery, or in a palliative perspective for patients in which surgery is not feasible.


Temporomandibular joint disorders (TMDs) are characterized by their multifactorial etiology and pathogenesis. A 3-year prospective study was conducted in a Portuguese TMDs department to study the prevalence of different TMDs signs and symptoms and their association with risk factors and comorbidities. Five hundred ninety-five patients were included using an online database: EUROTMJ. Most patients were female (80.50%), with a mean age of 38.20 ± 15.73 years. The main complaints were: (1) temporomandibular joint (TMJ) clicking (13.26%); (2) TMJ pain (12.49%); (3) masticatory muscle tension (12.15%). The main clinical findings were myalgia (74%), TMJ clicking (60–62%), and TMJ arthralgia (31–36%). Risk factors such as clenching (60%) and bruxism (30%) were positively associated with TMJ pain and myalgia. Orthodontic treatment (20%) and wisdom tooth removal (19%) were positively associated with TMJ clicking, while jaw trauma (6%), tracheal intubation (4%) and orthognathic surgery (1%) were positively associated with TMJ crepitus, limited mandibular range of motion, and TMJ pain, respectively. In total, 42.88% of TMDs patients had other associated chronic diseases, most of them were mental behavioral or neurodevelopmental disorders (33.76%), namely, anxiety (20%) and depression (13%). The authors also observed a positive association of mental disorders with the degree of TMJ pain and myalgia. The online database seems to be a relevant scientific instrument for healthcare providers who treat TMDs. The authors expect that the EUROTMJ database can serve as a milestone for other TMDs departments. Temporomandibular joint disorders (TMDs) are a group of dysfunctions that appear to be of multifactorial origin, affecting the temporomandibular joint (TMJ), masticatory muscles, and adjacent structures ,2. NowadIt is estimated that TMDs affect about 31% of the adult population and 11% of children/adolescents . TMDs prPsychosocial, environmental, biological, and neurophysiological factors are considered etiological entities significantly associated with TMD symptoms. Factors such as emotional stress (anxiety and depression), bruxism, occlusal disharmony, orthodontic treatment, masticatory dysfunction, and postural deviation are reported to increase the risk for TMDs ,4,7.The most prominent symptoms are restricted joint function with alteration of the mandibular physiological dynamics, muscular or articular pain that intensifies with mastication, headache, and TMJ noises. Limited mandibular range of motion, pain, crepitation, or clicking in TMJ palpation are all common signs of TMDs assessed during a clinical examination ,2.This study attempts to evaluate and analyze the prevalence of TMD clinical signs and symptoms in a Portuguese TMD department and their association with various sociodemographic and individual factors such as age, gender, oral behaviors, risk factors, and other comorbidities.European temporomandibular joint (EUROTMJ) is an online electronic medical database that allows data collection from patients with TMDs . The patA 3-year prospective study was conducted in a Portuguese TMD department from 1 August 2019 to 1 August 2022. This study was approved by the Instituto Português da Face ethics committee (PT/IPFace//RCT/0822/01). All enrolled patients gave their informed consent in writing, following current legislation. The inclusion criteria were: (1) registration of all the variables under study in a first consultation and (2) clinical diagnosis of TMDs. The exclusion criteria were severe medical problems or impaired cognitive capacity. All patients with inclusion criteria over these three years were included. Descriptive data and clinical outcomes were registered in EUROTMJ. Demographic data (date of birth and gender) was recorded. In the first consultation, patients were instructed to answer questions regarding their complaints , laterality (when applicable), and duration of the symptoms . They were also asked about parafunctional habits in their daily life, such as bruxism and clenching. A clinical record registered other comorbidities and potential risk factors for TMDs. The TMJ pain recording was accessed in the right and left joints through the Visual Analog Scale . The VASLIFE was accessed by asking: “If you could give a life impact score to your TMJ problem on a 0 to 10 scale, where 0 means no impact, and 10 means the maximum impact possible, what would be your score?” . Arthral2) was used to determine the associations’ presence, and its intensity was measured using Cramér’s V Coefficient (φc). A p-value < 0.05 was considered statistically significant. For a graphic representation of risk factors and other comorbidities, a percentage >1% was assumed.Data were analyzed using the GraphPad Prism  and IBM SPSS  software. The variables were expressed as the mean (±standard deviation (SD)) or frequency (%). The biserial correlation Pearson Test (rpb) assessed the variables’ correlation. The non-parametric Chi-square test  of whom were female gender . 86.39% The mean global TMJ pain in the right and left joints was 3.42 ± 3.01 and 3.34 ± 3.01, respectively a. The imConsidering only those patients who presented pain, pain right and left was 4.25 ± 2.83 and 4.34 ± 2.73, whereas VASLIFE was 6.67 ± 2.34 b. The maThe correlation of complaints was analyzed in Regarding parafunctional habits, 180 (30%) of the patients reported positively to bruxism, 138 (23%) at night, 35 (6%) at day and night, and 7 (1%) during the day. On the contrary, 212 (36%) said that they do not have bruxism habits, and 203 (34%) do not know . RegardiIn clinical evaluation, patients presented 38.02 ± 9.31 mm of MMO . The meaFive hundred twenty-seven patients were also questioned regarding the diagnosis of other diseases, and it was found that 226 (42.88%) of the patients had another illness, with 111 (21.06%) with one condition and 115 (21.82%) with two or more diseases a. In a tPotential risk factors described in the literature for triggering the onset of TMDs were also identified . In totaThe association of clinical variables and TMJ pain with demographic data, parafunctional habits, risk factors, and other comorbidities were then studied .p < 0.001, φc = 0.189, p < 0.001, φc = 0.154, p < 0.001, φc = 0.277, In the demographic data, sex has a strong association with pain , as reported in other studies .26%, as ,16, follIn our study, TMDs signs are more frequent than symptoms ,17. ThisFurthermore, TMJ pain was moderately correlated with LMO, while masticatory muscle tension had a moderate correlation with headache and cervical muscle tension. Almoznino, et al.  also shoThe most frequent possible causes for TMDs described by the patients included: (1) parafunctional habits (clenching (60%), bruxism (30%)); (2) previous orthodontic treatment (20%); (3) wisdom tooth removal (19%), (4) general dental treatment (14%), (5) jaw trauma (6%), (6) tracheal intubation (4%), and (7) orthognathic surgery (1%). Our study shows a strong association between clenching and bruxism with the degree of myalgia and a moderate association between clenching and TMJ pain. In addition, previous tracheal intubation, orthognathic surgery, and wisdom tooth removal were positively associated with a limited mandibular range of motion, TMJ pain, and TMJ clicking, respectively. These findings are in accordance with previous studies, such as Marklund et al. , which pRegarding other comorbidities, it is unclear to which extent TMDs may reflect symptoms or manifestations of underlying diseases. In the current study, although most of the patients evaluated had no comorbidities (57.12%), 42.88% of TMDs had other conditions and 21.06% presented only one disease. In comparison, 21.82% of the patients referred to two or more diseases.Almost one-third of these patients reported mental behavior and neurodevelopmental diseases, a pertinent factor for many patients with TMDs. A total of 20% had positive results for anxiety and 13% for depression. This study shows a correlation between mental behavioral and neurodevelopmental diseases with TMJ pain and myalgia. This result is consistent with other studies that demonstrated significant associations between stress, anxiety, depression, and TMDs ,27. HighOne of the strengths of this study was the consistency of a questionnaire and clinical examination to obtain reliable results for TMJ signs and symptoms in the first appointment. In addition, the EUROTMJ database allows the collection of data and evaluation of TMDs-related symptoms, correlating the findings with TMDs signs. This can be a valuable and applicable platform for TMDs screening and treatment decisions. Additionally, only one specialist examined all the patients in a TMDs-specialized appointment, making it an advantage of this study. However, as with most studies, the present analysis has limitations. Firstly, the database and questionnaire are not validated; furthermore, information bias might be present since the parameters evaluated using the VAS scale could be over or underestimated by the patients. Additionally, the evaluation of the correlation between TMDs signs and symptoms and TMJ diagnosis and proposed treatment was not included in this study, making it a limitation. Moreover, this study is single-center, which should be reproduced in a multi-center study.TMDs are a group of dysfunctions that affect a considerable part of the population nowadays, mainly younger female patients. In the subjects included in this study, TMDs were shown to be a group of disorders with a broad spectrum of clinical manifestations, pathophysiology, and associated comorbid conditions. Significant associations between TMDs signs and symptoms with intrinsic characteristics, such as age, gender, and parafunctional habits, such as clenching and bruxism, have been made. Positive correlations were also made with mental behavior and neurodevelopmental diseases, such as anxiety and depression, and other comorbidities, such as respiratory and endocrine alterations. Interestingly, risk factors such as wisdom tooth removal, orthodontic treatment, jaw trauma, tracheal intubation, and orthognathic surgery may increase the susceptibility to developing TMDs clinical symptoms. However, more studies are needed to understand such associations. We believe this data will serve as a milestone in providing helpful information for researchers and healthcare providers treating patients with TMDs.


Assessment is an important part of chronic pain rehabilitation and should be conducted in line with the current biopsychosocial conceptualization of pain to capture the subjectivity and context of pain. However, pain assessment is commonly conducted from a biomedical framework. A course in Acceptance and Commitment Therapy (ACT) was provided to spinal pain clinicians as a framework to promote more person-centered and psychosocially focused assessments and related psychologically informed practices. The purpose of this qualitative study was to explore the verbal content of clinicians’ communication with patients experiencing spinal pain in assessment situations before and after clinicians participated in an ACT course.Pain assessments of patients with chronic low back pain conducted by six spinal pain clinicians from different professions were audio-recorded and transcribed. This was done before and after participation in an eight-day ACT course with four following supervisions. A thematic analysis was carried out by two authors across all material, and a comparison of the applied number of codes pre-course and post-course was carried out as an indicator of change.Data consisted of transcripts from the six clinicians across 23 different patients (12 before course participation). Through analysis, 11 codes were developed, which were clustered in three overarching themes: Psychological domains, Communication Techniques, and Intervention Elements. Overall, there was an increase in the application of many of the codes in the transcripts from pre-course to post-course, however with large differences across codes. Increases were primary related to the discussion of life values and value-based action and quality of life as well as the employment of mirroring, challenging beliefs and assumptions, and addressing coping and pacing.While not the case for all factors, the present findings indicate an increase in including psychological factors and employing interpersonal communication skills after a course in ACT. However, it remains unknown due to the design if the changes reported in this study reflect a clinically valuable change and whether they are due to the ACT training itself. Future research will improve our understanding of the effectiveness of this type of intervention in assessment practices. Assessment is an integrated part of pain treatment and rehabilitation and is the foundation for ensuring optimal intervention and management . The curWhile psychologically informed pain practice is getting increased attention , many paACT is a third-wave cognitive behavioral therapy that focuses on the promotion of functioning and life quality rather than symptom control and reduction and has an embedded emphasis on values, context, and subjectivity , 11. ACTAuthentic exploration of how pain affects the life of the patient and what matters most in the patients’ life are important communicative practices requiring training. However, it remains unknown if ACT training could provide such a shift in assessment practices in non-mental health pain professionals. In the present project, ACT was therefore chosen as a framework for such training to promote assessments focusing on broader and psychological themes as well as applying related psychologically informed practices.The purpose of this study was to explore the change of verbal communication by clinicians with patients suffering from spinal pain in assessment situations before and after ACT training.The present study took place in a specialized regional spine center in Region of Southern Denmark, which supports around 1.2 million inhabitants. The primary purpose of the spine center is to assess patients with spinal pain and to refer to relevant treatment if needed. To be referred to the spine center, patients must suffer from ongoing and disabling pain (> 12 weeks) that they have received previous treatment for in primary sector. As a part of a project focused on improving patients’ quality of life and ability to take care of their own life situation, a team of spinal pain clinicians working at the spine center participated in an ACT course. The course was specifically designed for the short assessment contact with spinal pain patients as is the everyday reality at the spine center. The course was carried out with two ACT therapists and supervised by a certified ACT psychologist. The course consisted of two 2-day seminars and four full day courses over the course of five months continued by four 2-h sessions of supervision over the following months. For the purpose of the present qualitative study, data was collected from clinicians before and after participating in the course. Time between data collection pre-course and data collection post-course were approximately seven months, and time between end of training and post-course data collection was approximately three months, in which time the clinicians received supervision.A total of six spinal pain clinicians with expertise in managing patients with low back pain participated in the present study. Further information can be seen in the Result Section of this paper. Data consisted of audio recordings of the clinicians’ initial assessment consultations with different patients with spinal pain at the spine center. These assessments took around 30 min and were intended to evaluate the patient and to inform potential treatment. In most cases, the patient and the clinician were alone, but in one case a translator was present, in four cases patients were accompanied by a relative, and in four cases additional clinicians were present a part of the session. In one of these cases, an additional clinician was present for the first short part of the assessment (only speaking a few sentences), and in two other cases, an additional clinician was present in the latter part of the sessions. In the fourth case, two additional clinicians entered the sessions in the latter part. In all four cases, the dialogue was dominated by the clinician that was a part of the present study. Every clinician had to provide two recordings from both pre-course and post-course .The assessment encounters as well as the discussions in the analytical process were in Danish. The audio recordings were transcribed in a verbatim manner prior analysis by a research secretary in Danish, who knew both the population and the clinical terms. For publication purposes, citations were translated from Danish to English by SLR. In this process, sentence structure was mildly adapted to be meaningful in English.The first step of the analyses was overall familiarization with data. The analysis was a two-step procedure. First, a thematic analysis was carried out. Then, calculations of the number of applied codes were carried out. These two steps are outlined below.Thematic analysis was applied as inspired by Braun and Clarke , 14 to iAfter the thematic analysis, the second part of the analysis was carried out. Here, SLR and TEA compared the frequency of the different codes  in the pre-course and post-course material and calculated percentual change. This was used as a frequency indicator of different psychologically informed elements based on the assumption that each code indicated a paragraph of a psychologically informed elements. Hence, an increase in codes could be used as an indicator of increase of psychologically informed content and practices. Therefore, this was done as an additional analytical step to gain insight into potential changes in content before and after the course.The main study was approved by the Danish Data Protection Agency (file no. 1–16-02–477-16). According to the Health Research Ethics Committee of Region of Southern Denmark, the study did not need any further approval (file. no. 150/2016). Clinicians and patients gave written informed consent to have the assessments audio recorded and that this material could be used for research purposes.n = 20), and one clinician provided two pre-course and one post-course (n = 3), leaving a total of 23 transcribed clinical assessments encounters. The patients in these clinical assessment encounters were patients (both women and men) with ongoing low back pain referred to assessment at the spine center and were between 18 and 60 years of age.A total of six clinicians from different professions participated in the study: One chiropractor, one medical doctor, two physiotherapists, and two nurses. The clinicians’ mean age was 48 years, and 83.3% were women. They had a mean of 12.5 years’ experience working with low back pain and had a minimum of 6 years’ experience at the Spine Center before the ACT course (mean 7.3 years). Five clinicians provided two assessments both pre-course and post-course “So what obstructs you in doing all the things you would like to?” (Clinician 1)“What would it mean to you to find a solution to this? What difference would it make in your life?” (Clinician 3)”How does this bother you in your everyday life?” (Clinician 4)“ (..) Can you adjust in this so you still do some of the things that are important to you (..)?” (Clinician 5)“What is it that is important for you to be able to do?” (Clinician 6)Exploration of several psychological domains were identified in the transcripts. These were coded as: Quality of Life was applied for explicit questions about the patients’ perceptions of their quality of life as well as more implicit open questions about for example their general well-being or how a good everyday life looks like. This was, for example, asked in the following ways:“What does in fact give you quality of life?” (Clinician 1)“So a good everyday life to you, what is that?” (Clinician 1)“So are you satisfied with it as it is now? Well, you can say (..) that you have these challenges, but are you satisfied with your life as it is?” (Clinician 1)“How does this affect your quality of life? (Clinician 2)Further, the code Acceptance, was used for explicit communication about acceptance of life circumstances or learning to live with it. The final code in this theme, Emotions & Cognitions, was broadly defined and was used to any communication about emotional and cognitive elements. This could for example be direct questions about how the pain or the situation made the patients’ feel emotionally but could also be more implicit discussions or descriptions of the patients’ thoughts, expectations, and feelings. This did not include simple “what do think about this idea”-questions. Rather, this code is, for example, illustrated in the following quotes by Clinician 3:“How do you feel about this?”The third code, “How do you respond mentally, emotionally (..)?”Life Values & Value-based Action and Quality of Life were applied considerably more post-course compared to pre-course, while Emotions & Cognitions only was applied a little more, and Acceptance was applied less in the post-course compared to pre-course material. For visual overview, please see Fig. In addition to the above-outlined content of the first theme, we also explored the differences in the application of codes in pre-course material compared to post-course material. Overall, there was a clear increase from pre-course to post-course in this theme. In the pre-course assessments, the codes in this theme were applied 17 times, while they were applied 34 times in the post-course material, hence a 100% increase “I can see this makes you happy.” (Clinician 1)“I can hear this is also important.” (Clinician 3)Several communication techniques were applied in the assessments. These were coded as: , Open Questioning, was used to code open and broad questions about more person-centered, everyday life elements and not symptom nor activity specific elements. Generally, the clinicians were good at asking (open) questions, but these were often related to specific symptoms or activities. While this is also an important part of the assessment encounter, it was not considered a part of the developmental work in the present project and was therefore not coded. Follow-up questions as a natural part of a dialogue such as “what do you do then” were also not coded. This code was also used in cases where people had an emotional response in the room to open for a more emotionally focused dialogue – for example by asking the patient what they thought of their emotional reaction.The final code in this themeFor the overall theme, there was a small increase in the application of these techniques from pre-course to post-course. Specifically, the codes in this theme were applied 21 times in the pre-course material, while they were applied 25 times in the post-course material, hence a 19.05% increase “Could you imagine turning a little down for some of all the activities you have?” (Clinician 1)”Do you have the possibility to lower the strain at your work?” (Clinician 2)“What can you then do to ease it, when you feel like that?” (Clinician 2)“How do you handle your pain in your everyday life?” (Clinician 3)”But can we make it more optimal in your everyday life so your pain will be handled in a better way, so you in fact will experience less pain?” (Clinician 5)”Can you do things differently?” (Clinician 5)The next code, Challenging Beliefs & Assumptions, was used in cases where clinicians attempted to challenge the beliefs, assumptions, and perceptions of the patients – for example about the possibility to get pain free for example by talking to the patient about how realistic it was. In challenging beliefs and assumptions, the clinicians also often asked a series of questions like “What happens if you do not do this?” and “Why is this important?”. A specific example of such a dialogue can be seen in the following text from Clinician 6:“Do you think it is realistic to go to work without pain? Pain free?”Clinician: “Yes. (..) I hope so. I have to say so because this was my hope.”Patient:  “This makes me ask whether you need to be completely pain free before it is possible to be able to manage your work? (..) Or if this is the dream scenario?”Clinician:“It has to be comfortable to get up and go to work, so one can endure it.”Patient: “So one can endure it. To me, this is something a little else than being pain free, isn’t it?”Clinician: Further, the final code, Challenging Beliefs & Assumptions and Coping & Pacing. For visual overview, please see Fig. Further, we also counted and compared the number of applied codes in the pre-course material and the post-course material. For the overall theme, there was a large increase in the application of these elements from pre-course to post-course. In the pre-course assessments, the codes in this theme were applied 44 times, while they were applied 71 times in the post-course material, hence a 61.36% increase  challenging for them, which was not followed up by the clinician.The present qualitative study aimed to explore the content of clinicians’ communication with patients with spinal pain in assessment situations in a specialist spinal pain setting before and after clinicians participated in an ACT course to explore its impact on communication content. The ACT course was used as a framework to change the conversation from a biomedical focus to a biopsychosocial focus.First, we focused on the application of psychosocial domains and related psychologically informed practices across all material. Through the analytical process, we found a total of 11 codes clustered in three themes: i) Psychological domains, ii) Communication techniques, and iii) Intervention elements. With this, we found that even though the content of the assessments was still widely focused on biomedical features, there was also some important psychological domains and psychologically informed techniques that were included and employed. This illustrates some of the content that meaningfully can be included into assessment practices in such a setting.Life Values & Value-based Action, Quality of Life, Mirroring, Psychoeducation & Reassurance, Challenging Beliefs & Assumptions, and Coping & Pacing were addressed considerably more post-course compared to pre-course. The four codes of Emotions & Cognitions, Validation, Psychoeducation & Reassurance, and Open Questioning was used a little more in post-course material compared to pre-course, but around the same level, while the remaining codes of Acceptance and Check-backs were used less in the post-course material compared to the pre-course material. Hence, the overall findings indicate a positive change, with some differences across codes, from pre to post course using the pragmatic design embedded in the clinic. While it is not possible to draw any definitive conclusions on the potential effect of the course due to the design, this may indicate a larger awareness and curiosity in the assessments on some of these elements.Next, we focused on the differences in the application of codes in the pre-course and the post-course material. For all three themes, there was an increase in the application from pre-course to post-course. Looking at the specific codes, there were positive changes in 9 of 11 codes from pre-course to post-course. However, the magnitude of these increases was very different. While there was only a small difference over time in the second theme, Communication Techniques, there were large total increases in the two remaining themes of Psychological domains and Intervention Elements. Further, there were large variations in the applications of the specific codes within the themes. For about half the codes, a noticeable difference in application was identified from pre-course to post-course. Here, the five codes of ACT has become of increasing interest in chronic pain rehabilitation , 16, notAs an important part of the present study, there are some elements related to clinical and future perspectives that are important to discuss. As outlined above, the current conceptualization underlines pain as a biopsychosocial and multidimensional phenomenon . In the While the broader implementation of ACT is not necessarily without challenges , it holdAnother reflection from the present work is that future work in such practices is likely to benefit from a very specific aim and specific supervision afterwards. An important part of this is to consider why such a transformation is wanted, but also to reach agreement on how it specially look like in practice Spinal pain clinicians in assessment encounters are not psychotherapists, but rather need to be explorative on all life domains. Here, contextual factors – such as a short time frame – are also important to consider. This was aconsideration in the present study but is important to highlight and potentially further develop. It may also be beneficial to agree to some target areas that all clinicians should get around in their assessments – for example that of values – but also to agree on what to do with this information and how to use it to an individual, targeted approach.A last and very important point is that of clinical value. The present work did not enable us to establish whether the differences we found had any clinical relevance for neither clinicianexperiences nor patient experiences nor outcomes. Clinical value ought to be an important part of future work in this area, also including the patient perspective in order ensure assessments practices are valuable, relevant, and meaningful to the patients.While there are several strengths in the present study such as embedment in a clinical setting, there are also some important discussion points and limitations to take into consideration in interpretation of the results.First, some limitations exist related to the design of the study. These are natural consequences of the pragmatic study design embedded in clinical practice but are still of importance. With the design, we are unable to know whether the differences observed in the pre-course and post-course material were in fact associated with participation in the ACT course. Also, as the comparisons were in the same group of spinal pain clinicians but across different patients, the differences that are found may be affected by the shift in patients. In addition, there was one assessment less in the post-course material, leaving less material to code. In addition, some assessment contained other divergences, as mentioned in the methods section. This included the presence of a translator, relatives, and additional clinicians.. This may impact the content of the assessments and therefore the analysis of themes Further, clinicians as well as patients knew the aim of the study and the fact that they were being recorded. While this is unavoidable, one need to bear in mind that it may have impacted the dialogue.Second, some limitations were related to the analysis. Readers ought to be aware that some codes are similar in content, which may cause some overlaps in content. Further, the quantification of data by counting codes can be challenging . HoweverThe purpose of this qualitative study was to explore the content clinicians’ communication with patients with spinal pain in assessment situations before and after clinicians participated in an ACT course to explore its impact on communication content. This was carried out in spinal pain clinicians who received a training course in ACT as a framework to promote assessments focusing on broader and psychological oriented themes as well as applying related psychologically informed practices. Illustrated in 11 codes and three overall themes, the content of the assessment materials did consist of important psychologically informed elements and approaches. There were positive changes in 9 of 11 codes from pre to post course. While there were large differences in how much the content differed from pre-course to post-course, there was a clear increase in around half the codes. Despite of this, there is still room for improvement. While there are several limitations and points to consider, we hope to create focus on some important elements of chronic pain assessment and hereby inspire clinicians and researchers alike to engage further in this line of work to change our assessment culture to also embed psychologically informed elements and approaches. Future research will further improve our understanding of this type of training in assessment practices.


Sciatica is a common condition and is associated with higher levels of pain, disability, poorer quality of life, and increased use of health resources compared with low back pain alone. Although many patients recover, a third develop persistent sciatica symptoms. It remains unclear, why some patients develop persistent sciatica as none of the traditionally considered clinical parameters  are consistent prognostic factors.The FORECAST study (factors predicting the transition from acute to persistent pain in people with ‘sciatica’) will take a different approach by exploring mechanism-based subgroups in patients with sciatica and investigate whether a mechanism-based approach can identify factors that predict pain persistence in patients with sciatica.We will perform a prospective longitudinal cohort study including 180 people with acute/subacute sciatica. N=168 healthy participants will provide normative data. A detailed set of variables will be assessed within 3 months after sciatica onset. This will include self-reported sensory and psychosocial profiles, quantitative sensory testing, blood inflammatory markers and advanced neuroimaging. We will determine outcome with the Sciatica Bothersomeness Index and a Numerical Pain Rating Scale for leg pain severity at 3 and 12 months.We will use principal component analysis followed by clustering methods to identify subgroups. Univariate associations and machine learning methods optimised for high dimensional small data sets will be used to identify the most powerful predictors and model selection/accuracy.The results will provide crucial information about the pathophysiological drivers of sciatica symptoms and may identify prognostic factors of pain persistence.The FORECAST study has received ethical approval . The dissemination strategy will be guided by our patient and public engagement activities and will include peer-reviewed publications, conference presentations, social media and podcasts.ISRCTN18170726; Pre-results. This study has the potential to advance our understanding of the heterogeneity of pathomechanisms in people with sciatica and to identify factors that predict pain persistence.This data set will include the largest deeply phenotyped ‘sciatica’ cohort to date.Harmonisation with the PAINSTORM consortium  will afford integration of the FORECAST cohort (factors predicting the transition from acute to persistent pain in people with ‘sciatica’) into a much larger dataset of neuropathic pain.The large amount of data points collected for a modest cohort size will pose challenges for analyses and will require dimensionality reduction techniques.Patient recruitment will be challenging given the time intensive phenotyping protocol. This may lead to recruitment bias.Low back pain (LBP) is associated with more disability than any other condition.6–10It remains unclear why some patients develop persistent sciatica. Two recent systematic reviews have established that none of the traditionally considered clinical parameters  are consistent prognostic factors.These challenges in management and risk prediction are partly attributed to a lack of understanding of the pathomechanisms at play in sciatica. Sciatica is a heterogeneous condition likely caused by differing mechanisms in individual patients,The FORECAST study will examine the value of a mechanism-based deep phenotyping approach including main domains assessing nerve function, nerve structure, inflammation and psychosocial factors.The aims of the FORECAST study are:To explore mechanism-based subgroups in patients with acute/subacute sciatica.To investigate whether a mechanism-based approach can identify factors that predict pain persistence in people with sciatica.The FORECAST study is a prospective longitudinal prognostic factor cohort study that is based on feasibility data and closely informed by patient and public involvement and engagement (PPIE) activities including feedback from our named patient partners, six-member patient advisory group (PAG) and survey results from participants of the feasibility study. The study will be performed and reported according to the guidance for strenghtening the reporting of observational studies in epidemiology (STROBE)18We will include n=180 patients with acute/subacute ‘sciatica’ and n=168 healthy age and gender-matched participants without symptoms of sciatica/LBP. Healthy participants are important to establish normative values for blood markers, somatosensory profiling and neuroimaging.People aged >18 years with a clinical diagnosis of ‘sciatica’ will be recruited from primary care in Oxfordshire  and through leaflets on public noticeboards. Sciatica symptom onset of the current episode needs to be within the past 3 months with a symptom-free period of at least 3 months preceding the current sciatica symptoms. The inclusion criteria for patients with ‘sciatica’ are based on a published diagnostic model,The following exclusion criteria will apply; presence of other nerve-related disorders , previous lumbar spine surgery, serious spinal diseases , chronic inflammatory disorders, other pain conditions that may confound assessment , pregnancy, insufficient command of the English language to obtain consent/complete questionnaires and contraindications to MRI for those selected for scanning.After a preliminary eligibility screen on the phone , patient810.1136/bmjopen-2023-072832.supp1Supplementary dataThe final selection of our outcome measures has been guided by our PAG and feedback from participants in the feasibility study. Pain persistence will be defined with the sciatica bothersomeness index (SBI)22We may also run analyses using secondary outcomes ,24https://syp.spslab.ch). The derived variables  will be used to describe the symptoms associated with sciatica at baseline. These have been shown to provide clues about central sensitisation28 29See There is preliminary evidence that some quantitative sensory testing (QST) parameters may be prognostic in patients with a range of pain conditions including neuropathic pain.A shortened QST battery will first be conducted on the hand ipsilateral to the (most) symptomatic leg  to determine the presence of widespread hyperalgesia. The full QST protocol will then be performed in the area of maximal pain in the affected leg where pervious work has shown QST changes in patients with ‘sciatica’.31We will use healthy control data to calculate Z-scores, where each individual parameter is related to its region-specific, age-specific and gender-specific reference range. We will collect our own normative data, assisted by the provision of an existing QST dataset.Furthermore, we will include a conditioned pain modulation (CPM) paradigm to examine the efficacy of the descending pain modulatory system. Such dynamic QST protocols have shown most promising prognostic ability in other pain conditions.37 39There is a large body of evidence supporting the role of psychosocial factors in the persistence of pain and disability.We will sample blood by cubital venepuncture into BD Vacutainer SST and serum clot activator tubes . The time of last meal will be recorded. Thirty minutes after venepuncture, the blood will be centrifuged at 1.3 g for 10 min at 4°C  and at room temperature (red cap tubes for metabolomics). The serum fraction will be immediately aliquoted and stored at −80°C for batch processing.We will use complimentary protein/metabolomics analysis to evaluate serum inflammatory markers related to inflammation and neuropathic pain. Protein analysis will usecustom-made electrochemiluminescent multiplex biomarkers assays. These plates contain 17 cytokines/chemokines including candidates of interest derived in our previous work .Metabolomic analyses will be carried out using a state-of-the-art, high-field 700 MHz NMR spectrometer equipped with TCI cryoprobe , as previously described.We will also collect basic demographic data  and medical information .At the end of the baseline appointment, the assessor will rate the certainty of neuropathic leg pain as unlikely, possible, probable or definite according to the updated neuropathic pain grading system.We will also collect the following additional questionnaires to describe our patient population: ODIWe will perform magnetic resonance neurography (MRN) in a subset of n=100 patients with sciatica and n=44 healthy matched controls to identify moderate effects2) diffusion tensor imaging (DTI) scans, high-resolution anatomic scans with optimised T1 and T2-weighted contrasts, and a T2 mapping scan (DOI: 10.5281/zenodo.7760905). The data analysis will be performed using functional magnetic resonance imaging of the brain software library (FSL) tools including TOPUP68We will perform advanced MRN optimised to visualise lumbar nerve root macrostructure and microstructure at 3 Tesla using a dedicated 18-channel phased array spine coil . The protocol includes multishell  and their clinical course  will be described for short (3 months) and long-term time points (12 months).To identify and characterise mechanism-based subgroups in patients with acute/subacute sciatica and use distance-based clustering algorithms efficiently we first need to address the high dimensionality—modest sample size of the data set. Thus, we will first carry out a principal component analysis to summarise and reduce the dimensionality of the dataset while preserving as much variability as possible. Then we will use algorithmic centroid (k-means) and hierarchical clustering based on the Euclidean distance between principal dimensions to identify subgroups of patients sharing high phenotypic similarities. The optimal number of clusters will be determined using the gap statistic and the elbow of the within/between clusters variance plot. Consequently, we will perform hypothesis testing to assess group differences on the original variables between participants assigned to different clusters. All omnibus tests will be followed up by the appropriate post hoc test.To investigate factors that predict pain persistence in people with sciatica, we will use variable selection techniques followed by predictive modelling. First, we will perform filtering of the original variables by calculating the univariate associations  between variables and the outcome and between each other. We will select a subset of uncorrelated variables that are associated with the outcome and use them as input features in machine learning algorithms for high-dimensional, small data sets that will allow us to identify the most powerful predictors and assess model selection/predictive accuracy. During preprocessing, missing data will be examined, the mechanism of missingness will be inferred using hypothesis testing and visually assessed using a matrix of boxplots for all pairs of variables and the outcome, and, if appropriate, multiple imputation by chained equations will be used. Drawing from machine learning techniques for high-dimensional small data sets, we will use resampling and validation in the form of repeated cross-validation to perform a complete variable profiling to identify the most powerful predictors. Multivariate adaptive regression splines (MARS) with built-in feature selection and Decision Tree models known to work well on low sample sizes will be trained to predict the 3-month and 1-year outcome. Model performance will be estimated using five times repeated 10-fold cross-validation and compared with models trained on surrogate data.Published sample size guidelines for QST clustering in peripheral nerve injury6=64 patients to perform k-means clustering with adequate power.77Using the two first principal dimensions for three variable domains , we will need 2Assuming k=4 clusters, we will be able to identify moderate effects (effect size=0.25) with an one-way analysis of variance between four groups at an alpha level of 0.05, 80% power.FORECAST aims to identify prognostic factors (the first step in the PROGRESS framework)The FORECAST study has received ethical approval . All participants will provide informed written or electronic consent before participating in the study.The dissemination strategy will be strongly guided by our PPIE activities (see below). This will be based on coproductions between patient partners and academics and will involve publication of findings in scientific journals, presentations at conferences, media pieces  as well as communication through charity partners.https://alleviate.ac.uk) and remaining bio-samples will be on-boarded to the Imperial Biobank. The data and samples will continue to be linked and will be available for future studies.Data will be made publicly available on the ALLEVIATE data hub  inclusion of two patient partners as coinvestigators (CR and CP). They will contribute as equal partners on the investigator team; (2) PPIE lead with extensive experience in involving patients’ voices in research (KRM); (3) diverse PAG consisting of six individuals with a lived experience of sciatica. Our patient partners and PAG provided early input to the original grant application and identification of key research activities within the project, particularly around including the feasibility work , study design  and strongly informed the writing of our funding application .We will continue to work closely with people with lived experience of sciatica as we undertake this study, and our PPIE strategy will continue to be implemented throughout the lifetime of FORECAST. We will seek the perspective and guidance of our patient partners and PAG members on matters including, but not limited to participant recruitment and retention; barriers/facilitators of participation among seldom heard populations; data analysis and sensemaking of findings, organisation and coproduction of workshops, dissemination materials and public engagement activities. This will ensure that the patient perspective has been considered at all stages throughout the project.We will also work closely with our patient partners and advisors on engagement and dissemination activities. This may include, but is not limited to, coproducing newsletters, lay summaries, website content, infographics, animated videos, and podcasts, as well as engagement activities to bring the project into a public sphere. We plan to work closely with the PAINSTORM research team and patient partners as well as other national and international pain and sciatica groups to promote the study and its subsequent findings. This would allow us to reflect on the way the conclusions are presented and identify any gaps which might lead to further research in the topic area. We also plan to hold conversations with our patient partners and PAG regarding planning and undertaking academic dissemination activities . All individuals who contribute to this PPI advisory group will receive payment in accordance with current INVOLVE guidelines.


Nearly, 75% of patients post-CABG complain of moderate to severe pain during their hospital stay. Nonpharmacological interventions have been investigated; however, the effect of Holy Quran recital post-CABG is still not well studied, especially in developing Islamic countries.  To investigate the effect of listening to the Holy Quran recital on pain and length of stay post-CABG. t-tests.  This was a randomized control trial on 132 patients recruited from four hospitals in Amman, Jordan. The intervention group listened to the Holy Quran recited for 10 minutes twice daily while the control group received the usual care. Data were analyzed using paired and independent samples t-test testing showed that there was a significant reduction in the pain level,  for the intervention group. In addition, the intervention group had shorter LoS in the ICU and in the hospital compared to the control group, , , respectively.  Paired NCT05419554. Listening to the Quran was significantly effective in improving pain intensity among post-CABG patients and shortening their hospital/ICU stay. This trial is registered with  Open-heart surgery is currently carried out in industrialized and developing nations to extend patient lives and enhance the quality of life , 2. The It has been reported that up to 75% of patients complain of moderate to severe pain in the first 48 hours post-CABG , 6. The Furthermore, pain can make it difficult for patients to cough effectively, to breathe deeply, or to cooperate in physical therapy. It can also cause pulmonary secretions to be retained, which can result in consequences such as pulmonary atelectasis, pneumonia, and respiratory failure. These are considered serious complications after CBAG that might increase the length of stay (LoS) at the hospital postoperatively –13. HoweLength of stay is considered by administrators and healthcare providers as a key indicator of postoperative recovery. Moreover, it is a crucial sign of long-term healing and a proxy measure of acute physical recovery, respectively –15. ReduPain management strategies fall under two major umbrellas: pharmacological  and nonpharmacological  . MedicatResearchers have investigated the effects of several nonpharmaceutical strategies for reducing pain post-CABG, such as music therapy, rapid relaxation , foot reDespite that, different studies concluded that Quran recitation was an effective treatment for diverse issues regarding health. For instance, specifically for patients with cardiac conditions, listening to the Holy Quran was found to improve sleep quality after cardiac surgeries , decreasTo assess the impact of the interventions on the two groups (the intervention and the control), an RCT was carried out. The study population was composed of all eligible patients who were admitted to the study settings at the time of the study. Participants for this study were recruited using a consecutive sampling strategy. Every patient who visited any of the four main hospitals in Amman, Jordan, throughout the data collection period was sampled using this method by being checked for inclusion criteria. Up until the required sample size was reached, participants who met the inclusion criteria and consent to participate were included in the study. All patients who met the following inclusion criteria were included in the study: being at least 18 years old, having elective CABG surgery, being able to communicate with the researcher both during the intervention and the interview, being able to read and write Arabic, signed an informed consent form, and did not have any problem in hearing. Patients with hemodynamic instability were excluded from this study.t-test and independent t-test as the statistical tests for analysis . According to these presumptions, a paired t-test requires 34 participants per group, while an independent t-test requires 64 participants per group. A statistician used tables of random numbers to randomly allocate patients to intervention and control groups. The patients were given a sequential number. The researcher inserted it into a sealed, opaque envelope. The other researcher opened the package and then applied the positioning when it was time to position the patients. Due to the nature of the intervention, the nurses were not blinded to the allocation. The evaluation of the patient's results, however, was blinded. The RCT was carried out at four main hospitals in Amman, Jordan: two private, one educational, and one governmental  0.05 alpha, (2) 0.8 power, (3) 0.5 medium effect size, (4) two-tailed test, and (5) the paired rnmental .After being extubated and alert, the intervention group listened to the Holy Quran recited for 10 minutes twice daily at a time of 10 am and 2 pm for two days (often the second- and third-day postoperative). We chose Surah Al-Rehman because it is thought to be the most rhythmic surah in the Quran, and Qari Abdul Basit's recitation of it is both calming and powerful because it comes from the depths of his heart . Each hoAge, gender, marital status, smoking status, and employment status of patients were assessed by patient interviews or by reviewing medical records .Pain was assessed at baseline and another time on day 4 postoperatively using a 0 to 10 pain numeric scale. LoS  was abstracted from medical records after discharge and was reported in days.NCT05419554). Participants were given a thorough explanation of the study with assurances of anonymity, informed consent, and the freedom to leave at any moment without penalty. The informed consent form, which participants who accepted to participate in the study signed, allowed for the perusal of their medical records information. All data are maintained on a computer that has suitable coding and is password protected. This article makes use of aggregate data.Prior to collecting data, the project received approval from the IRB committee at the Applied Science Private University in Amman, Jordan, and from the chosen hospitals. The project was registered as a clinical trial . In addition, the intervention group had shorter LoS in the ICU and in the hospital compared to the control group  minimal.Recitation of the Holy Quran could soothe patients' hearts, heal their pains, and enhance mental health. Listening to the Holy Quran reduces the pain signal transmission to the central nervous system, leading to the relaxation of muscles, and diverting the mind from the pain. Moreover, it stimulates alpha brain waves which increases endorphin levels, enhances the stress threshold, creates a sense of relaxation, and then relieves pain . Pain anThe pain level improvement started in the follow-up assessment for patients in the intervention group. Researchers , 41, 42 In terms of LoS, the current study findings indicated that patients in the intervention group had shorter LoS in the ICU and the hospital compared to those in the control group. In other words, the findings of the current study reflected a significant difference in the number of days the patients stayed in both the ICU and hospital between both groups of patients in favor of the intervention group. The longer the ICU/hospital stays, the higher the risk for patient's postoperative complications such as healthcare-acquired infections and increased readmission rate . Longer Since patients' outcomes, i.e., less pain intensity and shorten LoS in the intervention group, were significantly better than those in the control group, nurse managers and clinicians would encourage spiritual care including listening to recitation to the Holy Quran for patients following post-CABG. Further studies are needed to compare the effect of listening to recitation to the Holy Quran on the pain level associated with different painful procedures, for example, removal of chest tube, use of incentive spirometry, and breathing and coughing exercises. Because pain is a subjective experience and feeling that could be affected by multiple variables, future studies better include the patients' subjective experience qualitatively. Also, to avoid the effect of social, psychological, or personal factors on the effect of the intervention, the use of the crossover method in future studies could increase the power of the study.Despite the homogeneity of the two groups, there are several factors that could affect the pain perception between patients in both groups. Pain experiences were not qualitatively examined, which might guide the ICU clinician in improving the delivered care.The present study revealed that listening to the Quran was significantly effective in improving pain intensity among post-CABG patients and shortening their hospital/ICU stay. Based on these findings, listening to the Quran recitations could be used to decrease the need for analgesics and sedatives among post-CABG patients. Further research is recommended to examine the interval, timing, and duration that listening to the Quran needs to be applied to optimize clinical benefits. Moreover, studies might compare the effect of listening to the Quran combined with other spiritual interventions post-CABG and also evaluate the pain experience using quantitative methods, subjectively and objectively, and qualitative ones to provide the clinicians with the full picture regarding the use of the intervention.