Chest pain is a common disease in children. Most cardiac specialists use echocardiography to evaluate the etiology of and screen for children’s cardiac chest pain. We analyzed the etiology and echocardiography results of children with chest pain in pediatric cardiology clinics, clarified the disease spectrum and evaluated the diagnostic value of echocardiography in screening cardiac chest pain in children.P < 0.05). In the preschool group, most of the patients were girls (51.4%), while in the school-age group and the adolescent group, most of the patients were boys (P < 0.05). Among the children  who underwent echocardiography, 108 children had positive results, and 3,097 children had negative results. Among the 108 positive results, 10 cases of cardiac diseases were related to chest pain. The sensitivity, specificity of echocardiography in the diagnosis of cardiac chest pain were 6.7, and 96.9%, while the positive predictive value and negative predictive value was 12.96 and 93.67%, respectively.The clinical data of children with chest pain aged younger than 18 years who admitted to the pediatric cardiology clinic of Beijing Anzhen Hospital between 2005 and 2019 were analyzed. The patients were divided into three groups, including the preschool group, the school-age group and the adolescent group. Total 3,477 children were enrolled in this study. 232 (6.7%) patients were caused by cardiac diseases and chest pain was of non-cardiac origin in 3,245 patients (93.3%). The incidence of non-cardiac chest pain in the adolescent group was significantly lower than the other two groups, respectively (91.4 vs. 94.9 vs. 94.3%, In children with chest pain who are admitted to pediatric cardiology clinics, chest pain is mostly benign and rarely due to cardiac diseases. The use of echocardiography in evaluating cardiac chest pain in children is of little diagnostic value and leads to excess costs for patients and the health care system. Chest pain is common not only in cardiology clinics, but also in other pediatric clinics. Different from the disease spectrum causing adult chest pain, children with chest pain always are benign, and very few are caused by cardiogenic diseases –5. For pTo date, few studies have reported the disease spectrum of chest pain in children who are referred to cardiology clinics , 6. StudFor children with chest pain as a chief complaint, doctors often let them undergo many auxiliary cardiac examinations to exclude cardiac disease when they are admitted to the cardiac clinic, such as electrocardiogram (ECG), echocardiography and Holter monitoring. Echocardiography is a non-invasive auxiliary examination which was used to assessment the structure and function of the heart and is widely used in cardiology clinics. Therefore, is echocardiography of high diagnostic value in assessing the etiology of cardiogenic chest pain in children? To date, no literature has been reported.This study analyzed the disease spectrum of children’s chest pain in pediatric cardiac clinics and evaluated the diagnostic value of echocardiography in screening children with cardiac chest pain.The clinical data of children with chest pain who admitted to pediatric cardiology clinic of Beijing Anzhen Hospital from 2005 to 2019 were analyzed. The disease was coded according to the 10th revision of the International Statistical Classification of Diseases and Related Health Problems (ICD-10). The exclusion criteria included that the clinical data of patients was incomplete. The study was approved by the Institutional Review Board oft Beijing Anzhen Hospital.The demographics, history of the present illness, past medical history, family history, and auxiliary exams of these patients were analyzed. According to the above content and results, we diagnosed the etiology of children with chest pain. And then based on the clinical diagnoses, we determined the disease spectrum of chest pain in children who were admitted to the pediatric cardiology clinic. Based on the cause of chest pain, we divided the patients into the cardiac chest pain group and the non-cardiac chest pain group. According to the age of the patient, we divided these patients into three groups, including the preschool group (3 years ≤ age ≤ 6 years), the school-age group (6 years < age ≤ 12 years), and the adolescent group (12 years < age ≤ 18 years). The sex distribution and the etiology of chest pain in different groups were analyzed. Patients with congenital adrenal insufficiency, systemic lupus erythematous, carnitine deficiency or juvenile rheumatoid arthritis were thought to have positive history of past illnesses. If the family member of the patients which had been diagnosed with pulmonary arterial hypertension, Marfan syndrome, cardiomyopathy, severe familial hypercholesterolemia or had sudden death, we thought the family history was positive.ECG reports were retrieved from the clinical medical records. Abnormal ECG showed pathological Q wave, deviation of the electrical axis, atrial enlargement, pathological ST-segment or T-wave changes, pre-excitation syndrome, high-grade atrioventricular block, frequent premature ventricular contractions, ventricular hypertrophy and supraventricular tachycardia.The results of other auxiliary exams including myocardial enzyme, echocardiography, chest X-ray and Holter monitoring results were analyzed according to the clinical reports.Until now, children with myocarditis, pericarditis, large ventricular septal defect, anomalous origin of the coronary artery, cardiomyopathy, pulmonary arterial hypertension, aortic dissection, moderate or severe left ventricular outflow tract obstruction, pulmonary embolism or arrhythmia were thought to have cardiac chest pain –5, 11–16Children with chest pain without a history of cardiogenic diseases were divided into the echocardiography group and the non-echocardiography group according to whether they underwent echocardiography. The etiology of children in the echocardiography group was analyzed, and the diagnostic value for cardiogenic chest pain was evaluated according to the results of echocardiography.x̄ ± SD). The χ2 test was performed to analyze the sex distribution and causes of chest pain. For the cardiogenic chest pain cohort, we calculated the sensitivity, specificity, positive and negative predictive values, and positive and negative likelihood ratios for echocardiography. The 95% CI for the sensitivity and specificity was computed by the Wilson method. A P < 0.05 was considered statistically significant.For statistical analysis, SPSS 20.0 was used. Count data are expressed as the frequency (percentage), and measurement data are expressed as the mean ± standard deviation (P < 0.05)  reported a chief complaint of chest pain, including 2,083 boys (59.9%) and 1,394 girls (40.1%). Girls (51.4%) were more common in the preschool group, while boys were more common in the school-age group (61.1%) and adolescent group (62.2%), and the sex distribution difference in the three groups was significant ( < 0.05) .P < 0.05) (232 patients (6.7%) were diagnosed as cardiac chest pain, and 3,245 patients (93.3%) were diagnosed as non-cardiac chest pain. In children with non-cardiac chest pain, 1,813 cases (52.1%) were idiopathic (unknown cause), 1,071 (30.8%) cases were skeletomuscular diseases, 348 (10.01%) cases were respiratory diseases, ten cases (0.3%) were gastrointestinal diseases, two cases (0.06%) were mental diseases, and one case (0.03%) was other condition . In the  < 0.05) .n = 166, 71.6%), followed by myocarditis , pulmonary arterial hypertension , Kawasaki disease , frequent premature ventricular contractions , dilated cardiomyopathy , pre-excitation syndrome , anomalous origin of the left coronary artery , and coronary-pulmonary arterial fistula .In 232 patients with cardiac chest pain, suspected myocarditis was the most common cause , followed by slipping rib syndrome , costochondritis , and straight-back syndrome .In 1,071 patients with skeletomuscular diseases, precordial catch syndrome was the most common cause , followed by pneumonia , acute asthmatic bronchitis , asthma , pleuritis , chronic cough , emphysema , and pulmonary tuberculosis .In 348 patients with respiratory diseases, bronchitis was the most common disease , followed by gastritis , esophagitis , and constipation .In ten patients with gastrointestinal diseases, gastroesophageal reflux was the most common cause , followed by musculoskeletal diseases (30.8%),respiratory diseases (10.01%),gastrointestinal diseases (0.3%), psychogenic diseases (0.06%) and other diseases (0.03%). In our study, the proportion of cardiac diseases in children as the cause of chest pain was only 6.7%, extremely low compared with other causes. Our result was consistent with Hanson CL’s, which showed that only one patient (0.7%) had a cardiac cause in children with chest pain admitted to the pediatric cardiology clinic . The proAbout the demographic characteristics of children with chest pain, some literatures have reported that female children with a mean age of about 10 years are often have chest pain , 20. OthEchocardiography is one of the most widely used, safe, non-invasive and cost-effective auxiliary examination in cardiovascular medicine . Most ofIn clinical practice, owing to echocardiography’s availability and non-invasive nature, it was often used by pediatric cardiologists to evaluate chest pain in children. Over the past 20 years, the application of echocardiography examination has grown significantly in both pediatric and adult settings, this trend is in accordance with an increase in the use of all diagnostic imaging in the United States –32. In 2Among the patients we enrolled in the study, 31 patients had a history of cardiac disease. In 3,446 patients with no history of cardiac disease, 3,205 patients underwent echocardiography. Based on the results of echocardiography, we found that the sensitivity, specificity, positive predictive value and negative predictive value of echocardiography for the diagnosis of cardiac chest pain were 6.7, 96.9, 12.96, and 93.67%, respectively. The sensitivity and positive predictive value are low, and the specificity and negative predictive value are high, indicating that the use of echocardiography in evaluating cardiac chest pain in children is of little diagnostic utility and contributes to additional costs for patients and the health care system. This is basically consistent with previous literature reports . TherefoIn this large retrospective study, we found that among preschool children with chest pain, girls were dominant, while for school-age children and adolescents, chest pain is more common in boys. The most common cause of chest pain in Chinese children admitted to pediatric cardiology clinic is idiopathic chest pain, and very few children suffer from chest pain caused by cardiac diseases. Echocardiography has low sensitivity and positive predictive value for the evaluation of cardiac chest pain in children, and it is of little diagnostic utility and contributes to additional costs for patients and the health care system. For the evaluation of children’s cardiac chest pain, a comprehensive analysis should be performed according to a child’s clinical manifestations, past medical history, physical examination, an appropriate auxiliary examination and family history should then be selected to identify and clarify the cause, which can not only save clinical resources but also reduce the economic burden on children and their families.The limitations of this study including: (1) This study was a single center study, which only represents the case composition of a single center. And the relevant data in this study might be affected by the hospital size, patients’ source, first line specialty and other aspects. In the future, to more accurately evaluate the disease composition spectrum of chest pain in Chinese children who are treated in pediatric cardiology clinics, multicenter and large sample research studies should be conducted for analysis. (2) This study was a retrospective study. Some data were missing, which may affect some results. In the future, we will perform further prospective research to clarify the reasonable application time of echocardiography in the diagnosis of cardiac chest pain in children.The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author/s.The studies involving human participants were reviewed and approved by Beijing Anzhen Hospital Ethics Committee. Written informed consent to participate in this study was provided by the participants’ legal guardian/next of kin.HD, LC, and GL conceptualized the research hypothesis and analyses. LC researched the data, performed all of the statistical analyses, and wrote the manuscript. XL reviewed and edited the manuscript. GL obtained informed consent and checked manuscript. All authors read and approved the final manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Visceral pain (VP) following laparoscopic sleeve gastrectomy remains a substantial problem. VP is associated with autonomic symptoms, especially nausea and vomiting, and is unresponsive to traditional pain management algorithms aimed at alleviating somatic  pain. The present study was performed to evaluate the safety and effectiveness of laparoscopic paragastric autonomic neural blockade (PG-ANB) in managing the symptoms associated with VP following sleeve gastrectomy.This prospective, double-blinded, randomized clinical trial involved patients undergoing laparoscopic sleeve gastrectomy at two high-volume institutions. The patients were randomized to laparoscopic transversus abdominis plane block with or without PG-ANB. The primary outcome was patient-reported pain scores assessed at 1, 8, and 24 h postoperatively. The secondary outcome measures were analgesic requirements, nausea, vomiting, hiccups, and hemodynamic changes immediately after PG-ANB and postoperatively.n = 72; control group, n = 73) were included in the study. The heart rate and mean arterial pressure significantly decreased 10 min after PG-ANB. The visual analog scale score for pain was significantly lower in the PG-ANB than in the control group at 1 h postoperatively (p < 0.001) and 8 h postoperatively (p < 0.001). Vomiting, nausea, sialorrhea, and hiccups were significantly less prevalent in the PG-ANB group. Patients in the PG-ANB group received fewer cumulative doses of analgesics at 1 h postoperatively (p = 0.003) and 8 h postoperatively (p < 0.001). No differences between the groups were detected at 24 h (p = 0.298). No complications related to PG-ANB occurred.In total, 145 patients (block group, PG-ANB safely and effectively reduces early VP, associated autonomic symptoms, and analgesic requirements after laparoscopic sleeve gastrectomy. Although seldom discussed, visceral pain (VP) is the most significant source of pain in the first 24 h following laparoscopic sleeve gastrectomy (LSG) and other laparoscopic procedures . The somPathways for visceral sensation are diffusely organized both peripherally and centrally. Although the stomach possesses intrinsic neural plexuses that allow some degree of autonomy, it largely depends on extrinsic neural inputs, particularly parasympathetic and sympathetic pathways. The sympathetic nervous system exerts a predominantly inhibitory influence over gastric musculature and motility, with afferent pathways stationed at the celiac ganglion. In contrast, the parasympathetic nervous system, consisting of the vagus nerve and its branches, exerts a predominantly excitatory influence over gastric tone and motility . The antAutonomic nerve blocks have been described in the pain management literature. Specifically, celiac ganglia blocks have been reported in managing chronic pain caused by foregut malignancies or pancreatitis , 13. In In a pilot observational study involving 35 patients, we observed improvement in the severity of VP in the epigastric and retrosternal areas and associated autonomic symptoms following PG-ANB . The effThe purpose of this study was to evaluate the safety and effectiveness of PG-ANB in the management of VP in the early postoperative period after LSG. We hypothesized that PG-ANB is safe, reduces VP and associated autonomic symptoms, and provides hemodynamic stability in the early postoperative period after LSG.This prospective, double-blinded, randomized clinical trial involved patients undergoing LSG at two high-volume bariatric surgery institutions. The patients were randomized to two parallel groups: LSG with laparoscopic TAP block only and LSG with laparoscopic TAP block and PG-ANB performed as a paragastric lesser omentum neural blockade. The study protocol adhered to the Helsinki Declaration and was approved by the Institutional Review Boards and the Ethics Committee of Clinica Portoazul and Clinica Iberoamerica. The study protocol was registered at ClinicalTrials.gov under the identifier NCT05353426 and published . FurtherAdult patients scheduled for LSG at each participating institution from Aug 25, 2021, to Feb 8, 2022, who consented to study participation were included. The exclusion criteria were an age of < 18 years, the performance of concomitant procedures in addition to LSG, allergies to medications included in the postoperative management protocol, and anesthetic or surgical complications related to the LSG that would alter the postoperative management protocol.The primary outcome was patient-reported pain scores using an 11-point visual analog scale for pain. The secondary outcomes were analgesic requirements; the presence of nausea, vomiting, hiccups, tachycardia, or hypertension; and the changes in the mean arterial blood pressure and median heart rate 10 min after the blockade. The mean arterial blood pressure and median heart rate in the control group were measured immediately after completing the methylene blue test and 10 min later, corresponding to the exact timing when the measurements were performed in the blockade group. Outcomes were assessed at 1, 8, and 24 h after surgery during the period of inpatient admission following LSG.p-value of 0.05 and a power of 0.80, we estimated that a total of 128 patients would need to be enrolled in this study. To allow for any potential loss to follow-up, we enrolled 150 patients in the study.Previously published data have indicated that differences of 1 to 2 points on an 11-point visual analog pain scale are clinically significant –18. BaseRandomization was performed using sealed envelopes prepared by the data manager and stratified by institution in blocks of six. The data manager stored the randomization list containing the final treatment assignments. Only the data manager had access to the randomization list throughout the study. These sealed envelopes were placed in the patient’s charts and could not be opened until the patient was in the operating room under general anesthesia. At that point, the surgeon became cognizant of group assignment but was not involved in assessing study outcomes or collecting data. Both the patient and the investigator assessing and recording study outcomes were blinded to the treatment arm assignments.The patient’s age, sex, body mass index, current medications, and medical and surgical history were prospectively recorded at the preoperative clinic visit during study enrollment with informed consent. An analog pain scale survey was administered by an investigator blinded to the patients’ groups at 1 h postoperatively (in the recovery room), 8 h postoperatively, and the following morning. The investigator recorded the need for analgesics; the presence of nausea, vomiting, retching, excessive salivation, and hiccups; and vital signs.p-values < 0.006.Continuous outcome variables were compared with two-sample t-tests. Categorical and binary outcome variables were compared using chi-squared tests. Patient-reported pain scores were further compared using linear regression with the surgeon who operated and the location of the procedure as covariates to assess the effect of the surgeon and place on the primary outcome. Given the multiple secondary outcomes  assessed at each time point in addition to the primary outcome, Bonferroni adjustment was used to limit type I error in the current study with statistical significance defined as Our two anesthesiologists used the same standard anesthetic protocol: premedication with Lyrica, induction with remifentanil, propofol, and rocuronium, and maintenance with desflurane and remifentanil. The analgesic protocol used in all patients before extubation consists of acetaminophen (1 g) and morphine (3–5 mg). Ondansetron and alizapride were used routinely during induction of anesthesia as antiemetics.The LSG technique performed by our group has been previously described in detail elsewhere , 10, 15.The laparoscopic TAP block was performed after testing the sleeve with methylene blue. We infiltrated 40 mL of 50% diluted 0.5% bupivacaine into the posterolateral subcostal area on both sides. We confirmed infiltration into the proper plane by observing the dissemination of the fluid between the transversus abdominis and internal oblique muscle layers. We no longer used sonography to confirm TAP blocks.https://youtu.be/BGs_1VpuVUw.The paragastric lesser omentum neural block was performed with a 25-gauge short needle attached to a venous catheter extension introduced through the left 12-mm port. The needle was capped during its introduction, and the cap was removed inside the abdomen using a grasper and kept under direct vision at all times. Infiltration of 20 mL of non-diluted 0.5% bupivacaine was performed at six levels in the fatty tissue of the paragastric area with careful aspiration preceding the infiltration of fluid. We ensured proper infiltration of the lesser omentum along the vagus nerve and distal branches at the esophagogastric junction, proximal stomach, mid-stomach, and distal antrum. Next, we infiltrated the area overlying the hepatic artery  or dipyrone (1 g intravenously every 6 h). The first-line rescue analgesic was a nonsteroidal anti-inflammatory drug such as diclofenac (intravenously every 12 h) together with hyoscine butylbromide (0.2 mg intravenously every 12 h), and the second-line rescue analgesic was Tramadol . Tramadol was the only opioid derivative used. After surgery, a popsicle was offered in the afternoon, and clear fluids were started the following day. Patients are discharged from the hospital in the afternoon the next day after surgery if they are hemodynamically within normal limits, tolerating clear fluids, and pain is controlled.In total, 163 patients were recruited for study inclusion. Thirteen patients were excluded prior to randomization . After excluding these patients, 150 patients were randomized to the PG-ANB group or the control group. As detailed in Fig. p = 0.6492). After exclusion, 145 patients were included in the final analysis: 73 in the control group and 72 in the PG-ANB group . The mean decrease in the mean arterial pressure was 10.3 ± 9.7 mmHg in the PG-ANB group and 3.3 ± 11.6 mmHg in the control group (p = 0.0001)  and 8 h postoperatively . When assessed on the morning of postoperative day 1, no difference was noted between the PG-ANB and control groups   Table .Table 3Pp < 0.0001 at both times points)  and 8 h postoperatively (p = 0.0001) (Table p = 0.0010)  Table . At 24 hNo patients developed complications related to the PG-ANB beyond mild, self-limited bleeding in three patients at one of the infiltration sites. All bleeding resolved intraoperatively without further intervention. The hemodynamic changes observed intraoperatively shortly after the block were well tolerated by the patients; in nine patients, the anesthesiologist administered phenylephrine (0.5–1 mg) and atropine (0.5 mg) to regulate the heart rate and mean arterial pressure. One patient developed postoperative bleeding requiring a blood transfusion. This did not require operative reintervention for management and was presumed to have originated from the right paramedian 5-mm port incision, given the extensive ecchymosis in this area. Subsequent sonographic evaluation of the abdomen showed that most of the limited intraperitoneal collection was localized to the right abdomen near this port. There were no leaks or other complications related to the LSG.Visceral pain is the predominant form of pain after many laparoscopic procedures, in particular LSG. Studies have demonstrated that up to 75% of bariatric patients are discharged from the postoperative recovery room with moderate to severe pain , 19.PONV remains a problem in LSG patients, with groups describing a high prevalence 65%) 24 h after surgery despite adequate prophylaxis , 20. PON5% 24 h aThis randomized controlled trial demonstrated the safety and efficacy of paragastric autonomic blockade after LSG as a multimodal pain and associated symptoms management therapy. The need for analgesics in general and opioids in particular was significantly reduced with the blockade. The control group required 70% and 34% more total doses of analgesics in the first 8 and 24 h after surgery, respectively, than the PG-ANB group. Similarly, the control group required three times more total opioid doses than the PG-ANB group in the same periods. The difference in the incidence of PONV between the PG-ANB and the control group was relevant. The differences in pain scores, associated symptoms, and analgesic requirements disappeared at 24 h postoperatively, paralleling the 0.5% bupivacaine half-life used in PG-ANB. The use of liposomal bupivacaine may improve the blockade duration.There was a significant reduction in the heart rate and mean arterial pressure 10 min after PG-ANB, which is a possible effect of sympathetic inhibition. We believe this observation early after PG-ANB can be used as an intraoperative marker of an effective blockade. Despite intraoperative differences, heart rate and arterial pressure did not vary between the groups in the postoperative period .Based on the literature on predisposing factors to postoperative pain and PONV, there are groups of patients that may especially benefit from the PG-ANB. We believe these patients to include those with allergic reactions to analgesics, chronic opioid users, and patients with chronic pain, previous history of postoperative nausea and vomiting and motion sickness. Ultimately, patient selection for the PG-ANB is beyond the scope of this study which focused on the safety and efficacy of this procedure.No complications related to PG-ANB occurred besides minimal bleeding in three patients at one of the infiltration sites. All bleeding was resolved intraoperatively by compression with a grasper for 3 min. One patient excluded after randomization developed postoperative bleeding requiring a blood transfusion. This did not require operative reintervention for management. The evidence suggested that the bleeding originated from the right paramedian 5-mm port incision and was not related to the PG-ANB.The reproducibility of the results of this study is a potential limitation given the introduction of a novel laparoscopic PG-ANB technique. Surgeons who perform these laparoscopic blocks should be skilled minimally invasive surgeons. After a short learning curve, the procedure can be executed relatively fast. The equipment is inexpensive and readily available. Using retractable needles like the Carr-Locke needle may make this procedure more widely adopted. We believe that with the help of the figures and videos in this manuscript, surgeons comfortable with performing LSG and other minimally invasive foregut operations should be able to perform PG-ANB.Another limitation of the study design is the lack of a placebo control. The decision to omit a placebo control was made after consideration of potential complications from injection during the procedure. Ultimately, the risk from these complications was not felt to outweigh the benefit of a placebo-controlled study design.This study may represent a new era in the multimodal management of pain and associated symptoms in upper gastrointestinal surgery. With further refinement, targeting pertinent autonomic pathways may allow for expanded indications of other surgical procedures such as colorectal, pancreatic, gallbladder, genitourinary, and other surgeries. The study may lead to several related investigations in the future, including further exploration of strategies to extend the duration of PG-ANB  as well as research on how to refine the timing of the performance of PG-ANB with consideration of performing the block earlier in the procedure  to potentially diminish anesthetic administration and the hemodynamic changes precipitated by the stomach division (such as tachycardia and hypertension).PG-ANB safely and effectively reduces nausea and vomiting, visceral pain, and analgesic requirements in the first 24 h after LSG.


Increasing lines of evidence indicate that traditional Chinese exercise (TCE) has potential benefits in improving chronic low back pain (CLBP) symptoms. To assess the clinical efficacy of TCE in the treatment of CLBP, we performed a systematic review of existing randomized controlled trials (RCTs) of CLBP and summarized the neural mechanisms underlying TCE in the treatment of CLBP.A systematic search was conducted in four electronic databases: PubMed, Embase, the Cochrane Library, and EBSCO from January 1991 to March 2022. The quality of all included RCTs was evaluated by the Physiotherapy Evidence Database Scale (PEDro). The primary outcomes included pain severity and pain-related disability.A total of 11 RCTs with 1,256 middle-aged and elderly patients with CLBP were included. The quality of all 11 included RCTs ranged from moderate to high according to PEDro. Results suggested that TCE could considerably reduce pain intensity in patients with CLBP. Overall, most studies did not find any difference in secondary outcomes .The neurophysiological mechanism of TCE for treating CLBP could be linked to meditation and breathing, posture control, strength and flexibility training, and regulation of pain-related brain networks. Our systematic review showed that TCE appears to be effective in alleviating pain in patients with CLBP. Incidence of low back pain (LBP) increases progressively with age ; it is eUnder this condition, traditional Chinese exercise (TCE), as a therapeutic mind–body exercise, has been widely concerned by researchers . TCE [i.1 PRISMA guidelines were followed (This systematic review was registered with the Open Science Framework (10.17605/OSF.IO/NWGSF).followed . PubMed,followed . The fol(1)Types of studies. We included only published articles from RCTs that examined the effect of TCE on LBP. The article language was limited to English.(2)Participants. All middle-aged and elderly patients (mean age > 35 years old) with a diagnosis of LBP were considered for this review.(3)Interventions. The interventions included different types of TCE . Clinical trials comparing TCE with no intervention, placebo , or other treatments  were included.(4)Types of outcome measures. Outcome measures should include at least one of two evaluations: pain and disability.Two authors independently screened all titles, abstracts, and main text of the relevant papers according to the inclusion criteria. Papers that did not match the criteria for inclusion were omitted. Disagreements were settled by discussion or a third reviewer. The following information was extracted from the selected articles: (1) published data ; (2) design of included studies ; (3) type of intervention ; (4) characteristics of participants (including baseline demographic information and diagnostic/inclusion/exclusion criteria); and (5) adverse effects.We used the Physiotherapy Evidence Database scale (PEDro) to assess the risk of bias for inclusion and the methodological quality of each study in this systematic review . Two autAs shown in All 11 included studies involving 1,256 patients with LBP examined the effect of different types of TCE on pain intensity. Ten studies suggested that TCE group outperformed the control group in terms of pain relief, but one of the studies found that the effectiveness of Qigong for pain relief decreased over time. Only one study found no significant difference in pain alleviation between the Qigong and the control groups .Of the 11 included studies, five studies investigated the effects of TCE on back functional disability, three studies evaluated the effect on quality of life (QOL), and four studies determined the effect on sleep quality and satisfaction. Three studies suggested that Tai Chi had effectively improved back pain-related disability compared with the control group . Phatthan = 10) and exercise group (n = 10) reported suspected adverse events   .Pain management in elderly patients with CLBP is particularly challenging, and long-term opioid use was associated with an increased risk of comorbidities , psycholPain intensity relates to the degree to which a person is harmed by CLBP and can be quantified to estimate the severity of pain . The resTCE focuses on the integration of mental regulation, breathing, and movement control in addition to internal energy regulation .First, as a foundation of mind–body interaction, meditation and rhythmic breathing can effectively boost vitality and induce energy to flow through the body, which in turn drives body movement to alleviate pain . Self-awSecond, TCE relieves pain by combining muscle strength, static balance, and dynamic balance, and these concepts are quite similar to other pain-relieving therapies, such as core stabilization training . TCE canIn addition to correcting postural control and enhancing muscle strength to relieve back pain, the pain-relieving effects of TCE may be linked to changes in TCE-induced brain activity. Long-term Tai Chi practice resulted in an increase in cortical thickness of the inferior segment of the circular sulcus of the insula as well as a decrease in the functional homogeneity of the left anterior cingulate cortex (ACC) , 2014. AThis systematic review has some limitations. First, it has location and language bias, with five studies from China, two studies from Germany, and only one study from Thailand, the USA, the UK, and Australia, which were all published in English. Second, the TCE intervention differed greatly in terms of exercise type , duration (6–24 weeks), frequency (2–5 times/week), and control group. In the future, a detailed categorization of different types of TCE programs and controls will be required. Third, most of the included RCTs did not adopt blind methods , which might lead to biased subjective expectations and exaggerate the research findings. Finally, most RCTs employed followed up for few months only, so the long-term efficacy of TCE in patients with CLBP remains unclear.This systematic review shows that TCE is beneficial in relieving pain and improving pain-related dysfunction for middle-aged and elderly patients suffering from CLBP. As a convenient, cost-effective therapy with few adverse events, TCE could be recommended for elderly patients with CLBP. Nevertheless, the long-term efficacy of TCE in elderly patients with CLBP must be assessed, and theories on how TCE could treat and prevent CLBP require further investigation. In the future, more controlled studies with larger scale and stricter quality should be conducted to explore the long-term efficacy of TCE in elderly patients with CLBP.X-QW and H-YX: software, formal analysis, data curation, writing – original draft preparation, visualization, and project administration. LH: conceptualization, methodology, validation, investigation, resources, supervision, and funding acquisition. S-HD and Q-HY: methodology, validation, and writing – review and editing. All authors contributed to the manuscript revision, read, and approved the submitted version.


Transcatheter arterial embolization (TAE) has long been used for hemostasis of traumatic or postoperative hemorrhage and embolization of tumors. Previous retrospective studies of TAE for painful bone metastases showed 60%–80% pain reduction with a median time to response of 1–2 days. Compared with radiotherapy and bisphosphonates, time to response appeared earlier than that of radiotherapy or bone-modifying agents. However, few prospective studies have examined TAE for this indication. Here, we describe the protocol for a confirmatory study designed to clarify the efficacy and safety profile of TAE.This study will be a multicenter, single-arm confirmatory study (phase 2–3 design). Patients with painful bone metastases from any primary tumor are eligible for enrollment. TAE will be the main intervention. Following puncture of the femoral artery under local anesthesia and insertion of an angiographic sheath, angiography will confirm that the injected region includes tumor vasculature. Catheter position will be adjusted so that the embolization range does not include non-target tissues. Spherical embolic material will then be slowly injected into the artery to embolize it. The primary endpoint (efficacy) is the proportion of subjects with pain relief at 72 h after TAE and the secondary endpoint (safety) is the incidence of all NCI Common Terminology Criteria for Adverse Events version 5.0 Grade 4 adverse events and Grade ≥ 3 necrosis of the central nervous system.If the primary and secondary endpoints are met, TAE can be a treatment choice for painful bone metastases. Trial registry number is UMIN-CTR ID: UMIN000040794.The study is ongoing, and patients are currently being enrolled. Enrollment started in March 2021. A total of 36 patients have participated as of Aug 2022.Protocol Version: Ver1.4, 13/07/2022. As life expectancy increases due to recent advances in cancer treatment, and the number of cancer patients increases due to an increase in cancer incidence resulting from an increase in patients surviving stroke and other cardiovascular disease, the number of patients with bone metastases is also increasing . It is rFor patients with painful bone metastases, there are different approaches to pain relief. Among current standard treatments, time to pain relief is 4 to 8 weeks in most patients receiving radiotherapy , 4 and 1Arterial embolization is used for hemostasis of traumatic or postoperative hemorrhage and for embolization to reduce tumor size by ischemia. Previous retrospective studies of arterial embolization for painful bone metastases –11 showeHere, we report the protocol for a confirmatory study of TAE, which aims to clarify the efficacy and safety profiles of this treatment.The purpose of this study is to clarify the efficacy and safety profile of TAE for painful bone metastases. This study is a collaboration between the Japan Interventional Radiology in Oncology Study Group (JIVROSG) and the Japan Supportive, Palliative, and Psychosocial Oncology Group (J-SUPPORT). This protocol has been reviewed by the J-SUPPORT Scientific Advisory Board, and approved as a JIVROS/J-SUPPORT1903 study (PALEM study).Cancer survivors and nonmedical persons were invited to attend the scientific advisory board meeting of J-SUPPORT. From protocol concept to writing the informed consent document, they participated in our discussion. Scientific advisory board members are listed on the following web page: Committees and Administrative Office | J-SUPPORT.This study is a multicenter, single-arm confirmatory study to clarify the efficacy and safety profile of TAE for painful bone metastases (phase 2–3 design).All participants will be recruited from 24 hospitals: Aichi Medical College, Aichi Cancer Center, Iwate Medical College, Cancer Institute Hospital of JFCR, Tonan Hospital, National Cancer Center Hospital, National Cancer Center Hospital East, Shizuoka Cancer Center, Juntendo Hospital, Teina Keijinkai Hospital, Hokkaido University Hospital, Ryukyu University Hospital, Osaka University, Kobe University, Keio University, Saiseikai Fukuoka Sogo Hospital, Nara City Hospital, Hakodate Goryokaku Hospital, Hyogo Cancer Center, Hyogo Medical University, Fukuchiyama City Hospital, Nara Medical Hospital, St. Marianna University Hospital, and Hokkaido Cancer Center.The protocol treatment will be performed on inpatients.To ensure the safety of subjects, registration will be suspended to evaluate safety once 20 subjects are recruited. In the exploratory phase, if any CTCAE Grade 4 adverse event or a Grade 3 or higher adverse event of central nervous system (CNS) necrosis occurs in at least 4 of the 20 subjects, the study will be discontinued (stopping rule) Fig. .Fig. 1St1) Diagnosis of painful bone metastases (multiple metastases are acceptable)2) The most painful bone metastases involve the thoracic spine, lumbar spine, pelvis, or rib(s), for which arterial embolization is expected to relieve pain3) No evidence of spinal cord compression on CT or MRI scan of the most painful bone metastases4) Numerical rating scale (NRS) score of ≥ 5 (Max10) for bone metastatic pain5) Current use of opioid analgesics6) No radiotherapy (RT) at the planned site(s) of TAE within the preceding 3 months7) No initiation of new chemotherapy or hormone therapy within the preceding 2 weeks8) Patients with any cancer9) Life expectancy > 1 month10) Normal renal function and no bleeding risk11) Age ≥ 20 years12) Ability to provide written informed consent to participate in the studyPatients fulfilling all the following criteria will be eligible for inclusion in this study:1) Inability to remain in the supine position2) Inability to describe pain on an NRS , 133) History of contrast media allergy4) Inability to discontinue anticoagulants, antithrombotics, or antiplatelet medication other than aspirin5) Childbearing potential6) Inappropriate for enrollment in the opinion of the investigator or sub-investigatorPatients fulfilling any of the following criteria will be excluded from this study:The study treatment will be performed in an angiography suite on an inpatient basis. An angiography device that can be used in digital subtraction angiography (DSA) is necessary. It is desirable that cone beam CT and/or CT angiography are available.As with conventional angiography, the femoral artery is punctured under local anesthesia to insert an angiographic sheath. Using an imaging catheter (parent catheter: 3 to 5 Fr) from the sheath, a parent vessel of the feeding artery is selected and imaged to localize the tumor and determine the vascular morphology. A microcatheter 1.7 to 2.5 Fr) is then inserted through the parent catheter to select arteries feeding the target lesion. After selecting the feeding arterial branches, angiography is performed to confirm that the relevant region includes abundant tumor stain, but not blood vessels in which embolization is contraindicated. The catheter position is adjusted so that the embolization range does not affect non-target tissues. Spherical embolic material is then slowly injected into the artery to embolize it , which are irregular in shape and diameter. It allows embolization of blood vessels of a specific target size with less proximal embolization, and contains fewer proinflammatory raw materials.All cancer treatments  that have been used since before enrollment in the study can be continued. Hydroxyzine, pentazocine, opioid analgesics, dexmedetomidine, and midazolam can be used as premedication before TAE. For post-embolization syndrome following arterial embolization, NSAIDs, acetaminophen, rescue opioid analgesics, and adjuvant analgesics can be used for transient exacerbation of pain, and antiemetics can be used for nausea.Subjects may not start any new cancer treatment  between enrollment in the study and assessment at 2 weeks after arterial embolization.The primary endpoint (efficacy) is the proportion of subjects with pain relief at 72 h after TAE.Compared with standard treatments for painful bone metastases, TAE is expected to produce a much more rapid response. Good pain relief may be achieved very rapidly after the start of palliative care by combining current standard treatments with TAE. Therefore, the proportion of subjects with pain relief as early as 72 h post-treatment is selected as the primary endpoint for immediate efficacy.The assessment method and response assessment will be conducted in accordance with the International Consensus on Palliative Radiotherapy Endpoints, an international consensus proposed for clinical trials of palliative radiotherapy for bone metastases . A respoThe secondary endpoint (safety) is the incidence of all CTCAE Grade 4 adverse events and CTCAE Grade ≥ 3 CNS necrosis associated with the arterial embolization procedure.In this study, the incidence of all CTCAE Grade 4 adverse events and CTCAE Grade ≥ 3 CNS necrosis associated with the arterial embolization procedure will be assessed in the 2-week post-TAE observation period.The incidence of all CTCAE Grade ≥ 2 adverse events associated with TAE will be investigated. Further, arterial embolization for painful bone metastases is not technically difficult and is thus feasible for clinical introduction; given that this may be a key point, the proportion of subjects treated with arterial embolization is included as another secondary endpoint.The incidence of adverse events will be calculated using the following equation:The proportion of subjects treated with arterial embolization will be calculated using the following equation:To investigate the timing, course, and duration of pain relief in response to arterial embolization, the proportions of subjects with pain relief at 24 h, 7 days, and 14 days are included as other secondary endpoints. The proportion of subjects with pain relief will be assessed based on the Brief-Pain Inventory-Short Form (BPI-SF) questionnaire .The proportion of subjects with pain relief will be calculated using the following equation:where “FAS” stands for “Full Analysis Set,”An improvement in KPS would provide an additional reason to use TAE instead of other methods. The proportion of subjects with an improvement in KPS is included as another secondary endpoint. An increase or decrease of ≥ 1 level will be counted as a significant change.To demonstrate that TAE is more effective than placebo, the proportion of complete responders will be assessed.The proportion of complete responders will be calculated using the following equation:The definition of an analysis set is the population of subjects enrolled in the study, excluding those who are doubly or wrongly registered Table .Table 1TIn addition, since pain with motion is generally uncontrollable, it would be clinically significant to demonstrate an improvement in this variable with TAE. The proportion of subjects with decreased pain with motion will be assessed based on the BPI-SF questionnaire. It will be comprehensively determined based on the improvement in maximum pain measured by Item 3 and the improvement in motion measured by Item 9.Patients will be registered online before the TAE protocol is initiated.After protocol treatment starts, several evaluations for pain and a general examination will be performed at 24 h, 72 h, 7 days, and 14 days after protocol treatment. The assessment schedule from enrollment to 2 weeks after protocol treatment is shown in Table The clinical hypothesis is that patients with painful bone metastases can be safely treated with arterial embolization for immediate pain relief.The early response rate after arterial embolization must exceed that after radiotherapy in order for arterial embolization to be established as a new palliative therapy. Since the early response rate was reported to be 26% at 1 week after radiotherapy , it is aAssuming that the threshold for the proportion of subjects with pain relief at 72 h after arterial embolization, i.e., the primary efficacy endpoint, is 26%, and the expected response rate is 40%, which represents the minimum clinical utility, at least 113 patients are required to provide a power of 90% at a one-sided significance level of 2.5% .On the other hand, an adverse event associated with TAE, which is the primary safety endpoint, is defined as any CTCAE Grade 4 adverse event or Grade ≥ 3 CNS necrosis. As described in “Common Adverse Events Associated with Arterial Embolization,” adverse events (including mild events) have been reported in 5% to 7% of patients who undergo arteriography, 10% of patients treated with arterial embolization, and approximately 15% of patients treated with TACE. Considering that patients in poor general condition will be included in this study, the unacceptable threshold incidence for the clinical use of this treatment is set at 15%, equal to that for TACE for hepatocellular carcinoma . AssuminNot applicable.This is not a blinded study for either clinicians or patients.The investigators will maintain individual records for each patient as source data, including a copy of informed consent, medical records, laboratory data, image data, patient diary, and other records or notes. All data will be collected by the J-SUPPORT Data Center at the National Cancer Center. Clinical data entry, data management, and central monitoring will be performed using an electronic data capture (EDC) system, Viedoc® 4 . Patient-reported outcomes will be collected using ePRO, Viedoc® Me (PCG Solutions).p-value will be calculated by a binomial test.As defined in the Section “Primary Endpoints,” the proportion of subjects with pain relief 72 h after arterial embolization and its two-sided 95% confidence interval (Clopper-Pearson method) will be calculated. It will be determined whether the lower limit of the two-sided 95% confidence interval is > 26%, the threshold response rate established at the time of study design. For reference, the p-value will be calculated by a binomial test.Safety will be evaluated in the Safety Analysis Set (SAS) Table . As defiIn principle, all analyses will be performed without imputation of missing values or outliers. However, if it is found before data lock that missing values or outliers may significantly affect analysis results, countermeasures will be described in a statistical analysis plan.In this study, we will examine the effect of TAE in providing immediate pain relief (within 3 days) for painful bone metastases. Palliative radiotherapy is one of the most commonly used modalities for painful bone metastases; however, its median time to pain relief is 4–8 weeks. Painkillers, including opioid analgesics, temporarily relieve pain but do not remove its cause. Therefore, a modality which can achieve immediate pain relief and remove its cause is necessary in this field. TAE may have the potential to achieve these goals.Since there is no standard treatment to compare with TAE for relieving bone metastatic pain in as short as a few days, this study will be conducted with a single arm. Because no quickly effective standard treatment is available, TAE, if shown to be quickly effective, will serve as a useful treatment option in clinical practice. In that case, TAE will be practically handled as one of several standard approaches; therefore, this study will be conducted as a confirmatory study. The study will also be conducted as a single-arm confirmatory study without controls in accordance with the Research Policy of Supportive and Palliative Care in Japan .Because TAE’s safety and efficacy have not been confirmed in a palliative setting, a prospective confirmatory trial is needed. Considering that palliative radiotherapy, pain killers, and TAE can be combined, we feel a randomized control study design comparing TAE with these other modalities is not necessary. In order to preserve the reliability of the results, we will evaluate efficacy and safety by maintaining strict thresholding and stopping rules.TAE is not a major tool in this field at present. If the primary and co-primary endpoints are met, TAE can be a treatment choice for painful bone metastases, and these results will potentially provide many benefits for all eligible patients with painful bone metastases.


Pain of the hand and wrist affects a large patient population. If the onset is unrelated to recent trauma, the first medical contact is rarely established with a specialized hand surgeon.The objective of this investigation was to (1) visualize the localization of hand pain using pain-related heatmaps in common wrist pathologies, (2) to test whether differences between these pathologies exist with regard to sociodemographic and pain-related aspects, and (3) to evaluate the major patient-reported complaints associated with the pathologies.This observational cross-sectional study included patients suffering from: thumb basal joint arthritis (CMC-1-OA), dorsal wrist ganglions, and TFCC tears. Patients marked the location of maximum pain projection on hand graphics depicting the outline of the palmar and dorsal hand. Color-graded frequency heat maps were generated for the wrist pathologies investigated. Daily life impairments were assessed and clustered into groups of functions/activities.120 patients with a mean age of 44.3 years were investigated. The diagnostic groups showed significant differences regarding the level and location of pain, as well as daily life impairments. Patients with CMC-1-OA presented with increased pain levels compared to patients with dorsal wrist ganglions and TFCC tears. Daily life impairment was rated highest when household chores were adversely affected, and sport activities were symptomatic/painful. All groups showed significant skin surface pain projection, which was visualized in heatmaps. While general trends in pain localization were visible, pain levels were also reported distal/proximal and palmar/dorsal to the pathology.Knowledge of main demographic parameters, pain projection, and degree of impairment in daily activities can help physicians to narrow differential diagnosis of wrist pain during first patient contact. Patients should then be referred to hand surgeons for specialist examination, to further differentiate the origin of the pain. Hand and wrist pain are common musculoskeletal disorders with a combined prevalence of approximately 10% in the general population . A varieManagement of wrist pain can be challenging and differential diagnosis often correlates with extensive work-up . In addiThis study investigated an innovative approach to visualize pain associated with three frequent wrist pathologies: CMC-1-OA, dorsal wrist ganglions, and TFCC tears. The specific aims were (1) to assess the level of pain and illustrate the self-reported location of pain on the skin surface, (2) to test whether there are differences between the diagnostic groups with regard to sociodemographic and pain-related aspects, and (3) to evaluate the major complaints associated with the pathologies.This observational cross-sectional study was designed as a retrospective study to explore and visualize the level and location of stress-induced pain in patients with three common wrist pathologies. The study was conducted at a level 1 hospital in Germany .Patients who presented with any of the three following common hand surgical diagnoses were included in this study: thumb basal joint arthritis (CMC-1-OA), dorsal wrist ganglions, and TFCC tears. Exclusion criteria included a recent operation in the specific area. Data were collected anonymously. The study was conducted between January 2020 and April 2021 and in accordance with the principles of the Declaration of Helsinki 1996, regional laws and good clinical practice. Prior to initiation, ethical approval was waived by the Institutional Review Board of the medical faculty LMU Munich (Ref.-Nr.: 22-0104).http://www.oracle.com/) , equal grid cells of all included patients were summed up according to their diagnosis. Then, their frequencies were encoded by the gradation of red color intensity. The darker the color, the more patients reported pain in this area of the hand Fig. .p ≤ 0.05. All calculations were performed using SPSS Statistics 29 .Data are presented as means with their respective standard deviation (1 SD), or as absolute and relative frequencies. Data were tested for normal distribution using the Shapiro–Wilk normality test and through visual inspection of Q–Q plots. Differences between diagnostic groups on a continuous dependent variable were calculated using one-way analysis of variance (ANOVA). Homogeneity of variances was calculated using Levene’s test of homogeneity of variances. Differences between diagnostic groups on dichotomous or multinomial dependent variables were assessed using the Chi-square or Fisher’s exact test as deemed appropriate. Answers to free text questions were clustered into groups of activities/functions and reported as absolute and relative frequencies. The level of significance was set at a probability level of In total, 120 patients  with a mean age of 44.3 ± 15.8 years participated in this study. Forty-three (36%) patients presented with a TFCC tear, 42 (35%) with CMC-1-OA, and 35 (29%) with a dorsal wrist ganglion. Overall, the mean level of pain across the entire patient population was 3.6 ± 2.4 (out of 10). Eighteen (15%) patients suffered from palmar, 72 (60%) from dorsal and 30 (25%) from both palmar and dorsal pain.p = 0.157). All groups included pre-dominantly females, with numbers being highest among the CMC-1-OA group  . Those suffering from CMC-1-OA were eldest with a mean age of 58.7 ± 6.8 years, followed by patients suffering from a TFCC tear with a mean age of 40.4 ± 14.2 years and a dorsal wrist ganglion with a mean age of 32.4 ± 12.5 years, respectively (Table Age differed significantly between the diagnostic groups p < 0.00. Those sp = 0.001). The mean level of stress-induced pain was highest in patients with CMC-1-Osteoarthritis (4.7 ± 1.8), followed by patients with a dorsal wrist ganglion (3.11 ± 2.8) and patients with a tear of the TFCC (3.02 ± 2.1) . Patients with CMC-1-Osteoarthritis suffered most frequently from pain in the dorsal hand , followed by combined palmar and dorsal pain  and lastly palmar pain only . In comparison, patients with a dorsal wrist ganglion reported pain in the dorsum of the hand in 80% (n = 28), both palmar and dorsally in 11% (n = 4) and isolated palmar pain in only 9% (n = 3) of cases. Patients suffering from a TFCC tear had pain in the dorsum of the hand in 61% (n = 26) of cases, both palmar and dorsal pain in 28% (n = 12), and palmar pain only in 12% (n = 5) of cases  most frequently, followed by limitations in household activities . The two most common impairments for patients with dorsal wrist ganglion were performing tasks requiring strength of grip , as well as sports . Patients with TFCC tears complained of limitations during daily household activities , followed second by tasks requiring strength of grip .Overall, patients reported limitations in daily activities due to wrist pathologies most frequently during daily household activities (20%), when performing sports 13%), at work (9%), when riding a bike (7%), during writing 6%), and computer tasks (4%), as well as functional impairments in activities requiring grip strength (20%), rotation (16%), or precision in grasp (6%). Detailed information is provided in Table %, at wor%, and coThis study investigated demographic variables, level, and location of pain as well as impairments and limitations in daily activities and functions in patients suffering from three common wrist pathologies. Using an unprecedented data collection manner, skin surface landmarks of pain location in patients suffering from CMC-1-Osteoarthritis, dorsal wrist ganglion, and TFCC tear were illustrated using color-coded heatmaps. While a plethora of technical devices, i.e., magnetic resonance imaging (MRI) or computer tomography (CT) scans are utilized to determine the etiology of wrist pain, medical history and clinical examination remain of utmost importance in diagnostics. This remains to be the case, especially pertaining to increasing economic pressure from health insurance providers and hospitals alike. A thorough specialist clinical examination can reduce unnecessary radiation, reduce financial strain, and allow efficient time management of both patients and surgeons. The results of this study help to narrow the potential diagnosis of patients with wrist pain and can guide practitioners toward initiating the correct diagnostic examinations. However, the results also highlight that there remains a level of ambiguity in self-reported location of pain, highlighting the need for specialist examination and diagnostic work-up by specialized hand surgeons.Patients with CMC-1-Osteoarthritis were as expected eldest, included mostly females, and reported the highest level of pain out of all investigated subjects. Naturally, osteoarthritis is an age-related disease , which iPatients suffering from a dorsal wrist ganglion, which originates in most cases from the scapholunate interosseous ligament , reporteRegarding TFCC tears, medical history helps to identify whether the patient suffers from an acute traumatic one-sided tear which is pre-dominantly found in young male patients, or a degenerative bilateral cause due to ulna variance, pre-dominantly found in female patients. The pain level to be expected is lower than that of CMC-1-OA or dorsal ganglion cyst. Bilateral conventional X-ray imaging is required in degenerative cases with ulna variance, while acute traumatic injuries require MR-arthrography or at minimum a conventional MRI –21.While, overall, the findings of this investigation are not novel per se, this study provides quantification and visualization of patient-reported pain levels and locations for the first time and using a novel approach. The data demonstrate that the information on age, gender, pain level, and location as well as impaired daily activities can guide the clinician to narrow possible differential diagnosis to the most common wrist pathologies. Color-coded heatmaps can provide guidance especially for young hand surgeons, orthopedic surgeons not specialized in hand surgery, as well as general practitioners in differential diagnosis of wrist pain. However, due to the remaining ambiguity in reported pain location, referral to a specialized hand surgeon is recommended. A multitude of diagnostic measures exist to further narrow the diagnosis of acute or chronic wrist pain. Especially radiological imaging is regarded paramount in determining the underlying disease. However, there are several radiographic views available  to best describe the suspected diagnosis. Hand surgeons are trained in physical examination of the hand and have knowledge of the radiologic assessments required. In terms of cost-effectiveness, after the initial narrowing of diagnosis by clinical investigation, patients should be referred to hand surgeons who can then decide upon further diagnostic measures for further clarification of the underlying disease.This study is not free of limitations. Distribution of standardized questionnaires, i.e., DASH, MHQ, and EQ-5D, and the evaluation of objectifiable measurement parameters such as grip strength or range-of-motion would have allowed further differentiation with regard to loss of function and the impact of the pathologies on quality of life.Color-coded heatmaps provide an innovative method to visualize the skin surface pain projection of common wrist pathologies. Knowledge of patients’ age, gender, level, and location of pain, as well as degree of restriction in daily activity allows physicians to narrow differential diagnosis. However, there remains ambiguity in self-reported surface projection of pain, thus potentially obscuring the correct diagnosis. Hence, after the initial clinical investigation and narrowing of possible diagnoses, patients with wrist pain should be referred to specialized hand surgeons who can then decide upon further diagnostic measures.