Material and methods: The study included six women, aged 22 ± 2 years, with primary dysmenorrhea (PD). A physiotherapist examined the tenderness and flexibility of the muscles. The patients were subjected to a gynecological and physiotherapeutic examination; the concentrations of progesterone and 17-beta-estradiol were also determined. In subgroup A (n = 3), manual therapy was performed 3 × 45 min; in subgroup B (n = 3), the patients received ibuprofen 3 × 400 mg/day. Results: In subgroup A, all patients showed a decrease in the level of progesterone and an increase in the concentration of estradiol. In subgroup B, the concentration of progesterone and 17-beta estradiol decreased in two subjects. In subgroup A, manual therapy reduced the severity of headache, back pain, diarrhea, fatigue, and PMS. In subgroup B, the use of ibuprofen only alleviated back pain and fatigue. Moreover, in subgroup A, after the application of manual therapy, improvement in flexibility and pain relief of the examined muscles was demonstrated. On the other hand, in subgroup B, no improvement in flexibility or reduction in muscle soreness was found in patients who took ibuprofen. Conclusions: Manual therapy may reduce menstrual pain in women with dysmenorrhea. However, the results need to be confirmed in studies conducted on a larger group of patients with dysmenorrhea.The aim of the study was to evaluate the effect of manual therapy and the use of ibuprofen on the severity of dysmenorrhea and changes in the level of sex hormones in young women with dysmenorrhea.  Previous research has demonstrated that dysmenorrhea is a complex process that depends on various factors ,2,3. BotThe menstrual cycle is determined by cyclical changes in the level of hormones, whose secretion is regulated by the feedback system of the hypothalamic–pituitary–gonadal axis . In the Pharmacological treatment, especially nonsteroidal anti-inflammatory drugs, is generally recommended to treat dysmenorrhea in young women ,13. ReceProctor et al.  describeIt is known that pain, including dysmenorrhea, causes stimulation of the sympathetic nervous system . The stiThe study included six women, aged 22 ± 2 years, with dysmenorrhea. The subjects were recruited in 2019–2020 through verbal advertising, social media, and a gynecological outpatient clinic. The patients enrolled in the study were randomly divided into two equal subgroups A and B. Subgroup A included three women, aged 22 years, with dysmenorrhea. Three women, aged 21, were also qualified to subgroup B. The subjects from subgroup A underwent manual therapy, with three treatments of 45 min each. The patients from subgroup B received ibuprofen at a dose of 3 × 400 mg daily for the duration of menstrual pain . The parQualification for the study was based on a structured interview. Women were asked about the regularity of the menstrual cycle, the duration of bleeding, the severity and duration of pain, the symptoms of premenstrual syndrome (PMS), and coexisting conditions . Patients were also asked about the reproductive system’s diseases, surgical procedures on the abdominal cavity and spine, medications taken regularly, and drugs used during menstruation. The study included nulliparous women in age 18-30 who had regular menstrual cycles, and who rated dysmenorrhea as five or more points on the NPRS . The excAfter patients with dysmenorrhea were qualified for the study, 5 mL of blood was collected from each subject during the first 3 days of the menstrual cycle (between 7:30 and 9:45 a.m.) in order to evaluate the levels of progesterone and 17-beta-estradiol. Blood samples were analyzed according to the standard procedures of the Invicta Medical Diagnostic Laboratory in Gdańsk, Poland. The levels of 17-beta-estradiol and progesterone were determined using the ECLIA electrochemiluminescence method according to the manufacturer’s instructions. In each woman, blood tests were performed twice. In subgroup A, blood was collected before and after manual therapy; the patient could not take analgesics until blood was collected. In subgroup B, blood was collected first during menstruation without taking medications; then, during the next menstrual period, the blood was taken while taking ibuprofen.After menstruation, women from subgroup A and subgroup B were subjected to a physiotherapeutic examination. A physiotherapist examined the soreness and flexibility of the following muscles: the diaphragm, iliopsoas muscles, adductors of the thighs, quadratus lumborum, hamstring group, piriformis muscles, and tensors fasciae latae. The tenderness of the muscles was examined by palpating the trigger points according to Simons and Travell  35,36].,36.35,36All women from subgroup A were subjected to manual therapy during one menstrual cycle. The therapy was performed once a week, and each session lasted 45 min. The subjects underwent three treatment sessions, depending on the duration of the menstrual cycle. The therapy included mobilization of the breathing diaphragm, post-isometric relaxation, and trigger point therapy according to Simons and Travell  35,36].,36.35,36In subgroup B, there were no interventions during the menstrual cycle. During the next menstrual period, the patients were asked to take ibuprofen at a dose of 3 × 400 mg daily for the duration of pain .The study was approved by the Bioethics Committee of the Medical University of Gdańsk (No. NKBBN/475/2018). The research was conducted in accordance with the principles of the Declaration of Helsinki as revised in 1996.n = 3), the mean age of subjects was 22 years, body mass index (BMI) = 21 kg/m2, the mean duration of the menstrual cycle was 27 days, and the duration of menstruation was 5 days. In group B (n = 3), the mean age of patients was 21 years, BMI = 24 kg/m2, the mean duration of the menstrual cycle was 30 days, and the mean duration of menstruation was 6 days.2. The physiotherapeutic examination showed the pelvis in anteversion.A patient with dysmenorrhea, 24 years of age, with a BMI of 24 kg/mThe manual therapy led to an increase in the difference in chest circumferences measured during inhalation and exhalation from 7 to 11 cm. Pain and increased tension of the breathing diaphragm were reported during the first and second examination. Manual therapy reduced pain of the iliopsoas muscles, adductors of the thigh, tensors fasciae latae, piriformis, left quadratus lumborum, and hamstring group on the right side. Furthermore, an improvement in the flexibility of left tensor fasciae latae and quadratus lumborum muscles was observed. However, there were no changes in the flexibility of hamstring group muscles and right tensor fasciae latae.After the manual therapy, the severity of menstrual pain decreased from eight to three points on the NPRS scale, with the duration of pain shortened from 3 to 2 days . Before Before the manual therapy, the level of progesterone was 0.54 ng/mL vs. 0.31 ng/mL after the treatment. The concentration of estradiol was 53 pg/mL and 60 pg/mL, before and after the treatment, respectively .2. The pelvis was in an intermediate position.A patient with dysmenorrhea, 22 years of age, BMI 20 kg/mThe palpation examination performed before the manual therapy showed that the breathing diaphragm was overly tense and painful, with normal tension and no pain were reported after the treatment. The manual therapy led to a reduction in the difference in chest circumference during inhalation and exhalation (6 cm vs. 5 cm).The manual therapy led to a reduction of pain of the quadratus lumborum muscles and the hamstring group on the right side. However, no changes were observed in the tenderness of the iliopsoas muscles, adductors, tensors fasciae latae, and piriformis muscles. The manual therapy did not improve the flexibility of the quadratus lumborum muscles, the hamstring group muscles, and tensors fasciae latae.Before the therapy, the patient evaluated menstrual pain as eight points on the NPRS scale; after the treatment, the severity of menstrual pain decreased to one point, while the duration of menstrual pain was shortened by 1 day . The dur2. The pelvis was set in anteversion. Before and after the therapy, the patient showed increased tension of the breathing diaphragm; the difference in chest circumference during inhalation and exhalation was 7 cm. After manual therapy, tenderness of the breathing diaphragm disappeared. Manual therapy reduced the soreness of the iliopsoas muscles, quadratus lumborum muscles, and piriformis muscles. Manual therapy did not affect the flexibility of the right tensor fasciae latae, quadratus lumborum muscles, and hamstring group muscles.A patient with dysmenorrhea, 20 years of age, BMI 20 kg/mBefore manual therapy, the patient scored her menstrual pain at seven points on the NPRS scale; after the treatment, the pain decreased by three points. The duration of pain, both before and after manual therapy, was 2 days . The durAfter manual therapy, the patient showed a lower level of progesterone (0.26 ng/mL vs. 0.22 ng/mL) and a higher concentration of estradiol (5 pg/mL vs. 12 pg/mL) .2. The pelvis was set in retroversion. The examination performed before and after the administration of ibuprofen revealed pain and increased tension within the breathing diaphragm; the difference in chest circumference during inhalation and exhalation was 4 cm. The palpation examination showed no impact of ibuprofen on the reduction in pain within iliopsoas muscles, adductors of the thighs, quadratus lumborum muscles, piriformis muscles, and hamstring group muscles. There was also no influence on the flexibility of quadratus lumborum muscles, hamstring group muscles, and left tensor fasciae latae. During the second examination, the right tensor fasciae latae was sore, but its flexibility improved.A patient with dysmenorrhea, 22 years of age, BMI 24 kg/mThe patient evaluated menstrual pain without taking medications as seven points on the NPRS scale. While taking ibuprofen at a dose of 3 × 400 mg a day for the duration of pain, the pain decreased to two points on the NPRS scale . The menThe concentrations of hormones determined during the use of ibuprofen revealed a lower level of progesterone (0.58 vs. 0.33 ng/mL) and estradiol (13 pg/mL vs. <5 pg/mL) .2. Upon physiotherapeutic examination, the pelvis was set in anteversion. The first physiotherapeutic examination showed no tenderness and normal tension of the breathing diaphragm; the difference in chest circumferences during inhalation and exhalation was 6 cm, while this difference was 5.5 cm during the second examination. The palpation examination revealed pain of the iliopsoas muscles, adductors of the thighs, and hamstring group muscles. There was shortening of the quadratus lumborum muscles and hamstring group muscles. During the second examination, a change was found in the right piriformis muscle because of its soreness. The patient was unable to evaluate the flexibility of the tensors fasciae latae due to her inability to relax the lower limb during the examination.A patient with dysmenorrhea, 22 years of age, BMI 22 kg/mInitially, the patient scored menstrual pain at seven points, while it was scored as four points when taking ibuprofen on the NPRS scale . Before Before pharmacological therapy (ibuprofen) was applied in the patient from subgroup B, the levels of progesterone were 0.21 ng/mL vs. 0.17 ng/mL after ibuprofen administration. On the other hand, the concentrations of estradiol before and after pharmacological therapy were 50 pg/mL and 21 pg/mL, respectively .2. The pelvis was set in anteversion. There was no effect of taking ibuprofen on pain and increased tension of the breathing diaphragm. During the second examination, the difference in chest circumference on inhalation and exhalation decreased from 7.5 cm to 5 cm. Ibuprofen did not have an impact on the soreness of iliopsoas muscles, adductors, quadratus lumborum muscles, piriformis muscles, and tensors fasciae latae. Moreover, there were changes in the flexibility of the right iliopsoas muscle, adductors, quadratus lumborum muscles, and hamstring group muscles. In addition, the examination performed after the use of ibuprofen revealed soreness of the hamstring group muscles. The flexibility of tensors fasciae latae was not examined because the patient was unable to relax the lower limbs during the examination.A patient with dysmenorrhea, 20 years of age, BMI 26 kg/mIbuprofen reduced the severity of menstrual pain from 10 to two points on the NPRS scale; the menstrual pain lasted 4 days . The menBefore the pharmacological therapy (ibuprofen) was applied in the patient from subgroup B, the levels of progesterone were 0.14 ng/mL vs. 0.31 ng/mL after the ibuprofen administration. On the other hand, the concentrations of estradiol were 0.18 pg/mL and 25 pg/mL, respectively, before and after the pharmacological therapy .Our physiotherapeutic examinations to evaluate the flexibility of muscles and the trigger points performed in all patients with dysmenorrhea showed disorders of the following muscles: iliopsoas, adductors of the thigh, quadratus lumborum muscles, and hamstring group muscles. Dysfunctions of the breathing diaphragm, piriformis muscles, and tensors fasciae latae were found in five subjects. In all patients with dysmenorrhea from subgroup A, manual therapy led to pain relief within the quadratus lumborum muscles. In two patients from subgroup A, manual therapy resulted in a reduction in pain within the iliopsoas, tensors fasciae latae, piriformis muscles, and hamstring group muscles, and it resulted in less severe pain of the adductors in one patient. In subgroup B, patients with dysmenorrhea receiving ibuprofen showed no improvement in flexibility and a reduction in muscle soreness. Moreover, one patient with dysmenorrhea from subgroup B showed excessive tension within the tensors fasciae latae and hamstring group muscles.We believe that the decrease in soreness and improvement in muscle flexibility in patients from subgroup A resulted in a reduction in menstrual pain. An analgesic effect was obtained in all patients from subgroup A. The changes in the severity of menstrual pain ranged from three to eight points on the NPRS scale. As no studies have described dysmenorrhea therapy using post-isometric relaxation techniques and the therapy of trigger points, we refer our results to other forms of manual therapy, such as osteopathy and spine manipulation ,40,41.ThThe patients with dysmenorrhea from subgroup B who received ibuprofen also showed a reduction in the severity of menstrual pain by three to eight points on the NPRS scale. The comparable effectiveness of manual therapy and ibuprofen was also confirmed in the study conducted by Barassi et al., who used neuromuscular manual therapy and ibuprofen to reduce dysmenorrhea. The authors obtained a comparable analgesic effect to our results .In addition to reducing menstrual pain, manual therapy shortened the duration of menstrual pain in two patients from subgroup A. This was not found in subjects from subgroup B while taking ibuprofen. The effect of manual therapy, i.e., shortening of the duration of menstrual pain, is consistent with the results obtained by Schwerla et al. , who demFurthermore, in a further stage of our study, we attempted to assess the impact of manual therapy in patients from subgroup A and ibuprofen in subjects from subgroup B on the level of sex hormones.In all the patients with menstrual pain from subgroup A, manual therapy resulted in a lower level of progesterone compared to the concentration before the treatment. In subgroup B, while taking ibuprofen, a lower concentration of progesterone was found in two patients. In patients with dysmenorrhea, manual therapy probably had an effect on the reduction in progesterone concentration. Our study results differ from the outcomes obtained by Roomruangwong et al., who showed that a lower level of progesterone is associated with a higher risk of menstrual pain and the related symptoms .We analyzed the effect of manual therapy and the use of ibuprofen on the concentration of 17-beta-estradiol in young women with dysmenorrhea. Manual therapy led to a higher level of 17-beta-estradiol in all patients from subgroup A. In subgroup B, a lower concentration of 17-beta-estradiol was detected in two patients . There iThe results of our study showed that the treatment was more effective than the use of ibuprofen in reducing the severity of coexisting symptoms in young women with dysmenorrhea. In subgroup A, manual therapy led to a reduction in the severity of back pain in all three patients, while, in subgroup B a similar effect was obtained in only one patient. Manual therapy reduced the intensity of headache in two patients from subgroup A and in one patient from subgroup B. Moreover, in group B, an increase in the severity of headache was demonstrated in two patients while taking ibuprofen. Initially, diarrhea occurred in only one patient from subgroup A and in two women from subgroup B. Manual therapy reduced the severity of diarrhea; this effect was not reported in women taking ibuprofen. Vomiting occurred only in two patients (A3 and B3). In patient A3, manual therapy did not have an impact on the severity of vomiting, while, in patient B3, ibuprofen reduced the condition. There were no episodes of fainting in women from subgroup A, while, in subgroup B, a reduction in syncope with ibuprofen was demonstrated in one patient. The feeling of fatigue during menstruation was present in all the subjects . We demoMoreover, our studies showed that, in addition to menstrual pain and the related symptoms, manual therapy decreased the severity of PMS in women from subgroup A. In subgroup B, ibuprofen did not demonstrate an effect on the intensity of PMS. However, it is worth noting that the patients from subgroup B took ibuprofen only from the onset of menstruation, with the lack of a real effect of the drug on the PMS symptoms. A reduction in PMS severity after manual therapy is consistent with the outcomes of the study conducted by Hernandez- Reif et al., who effectively treated PMS with a series of massages . The useIn our study, an analgesic effect was achieved in all patients from subgroup A and in two patients from subgroup B. However, manual therapy was more effective in reducing the severity of symptoms coexisting with menstrual pain and the severity of PMS symptoms. Moreover, manual therapy led to an improvement in the flexibility and muscle tenderness. On the other hand, patients from subgroup B taking ibuprofen showed no improvement in flexibility or reduction in tenderness of the muscles. Furthermore, one patient with dysmenorrhea from subgroup B showed excessive tension of the tensor fasciae latae and hamstring group muscles.The present study has some limitations that we would like to address. First, our study included no untreated control group, and we cannot exclude a placebo effect. Second, the research presented was based a small group of patients. Further cohort and longitudinal studies are being conducted to verify our findings and to garner a deeper understanding.We believe that the decrease in soreness and improvement in muscle flexibility in patients from subgroup A resulted in a reduction in menstrual pain. The study results indicate that manual therapy can be effective in relieving menstrual pain. However, the outcomes require confirmation in studies conducted on a larger group of women with dysmenorrhea.


Background: Severe postoperative pain is a significant problem after cesarean sections. Methods: This study was a randomized, controlled trial of 105 patients conducted in two hospitals. All patients were anesthetized spinally for elective cesarean section. Each participant was randomly allocated to one of three study groups: the quadratus lumborum block (QLB) group, the transversus abdominis plane block (TAPB) group, or the control (CON) group. The primary outcome of this study determined acute pain intensity on the visual analog scale (VAS). The secondary outcomes determined morphine consumption and chronic pain evaluation according to the Neuropathic Pain Symptom Inventory (NPSI) after hospital discharge. Results: At rest, the pain intensity was significantly higher in the CON group than in the QLB and TAPB groups at hours two and eight. Upon activity, the pain in the control subjects was more severe than in the QLB and TAPB groups in three and two of five measurements, respectively. Moreover, morphine consumption was significantly lower in the QLB (9 (5–10)) and TAPB (10 (6–14)) groups than in the CON (16 (11–19)) group. Persistent postoperative pain was significantly lower in the QLB group than in the CON group at months one and six following hospital discharge. Conclusions: Both the QLB and TAPB can improve pain management after cesarean delivery. Moreover, the QLB might reduce the severity of persistent postoperative pain months after cesarean section. Cesarean section is among the most common surgical procedures globally, and its use is on the rise in developed countries . Most scIn recent years, novel ultrasound-guided regional analgesia techniques have been implemented in multimodal and rescue analgesia. The transversus abdominis plane block (TAPB) and the quadratus lumborum block (QLB) are new types of truncal plane blocks, and their roles in post-cesarean section pain management are still under investigation ,7. It haSeveral randomized controlled trials (RCTs) have investigated the role of the QLB in acute postoperative pain after cesarean section ,12,13,14Our study aimed to reevaluate the impact of the QLB and the TAPB on acute pain occurrence in patients after elective cesarean delivery. Chronic postoperative pain development and severity were also investigated among these individuals.ClinicalTrials.gov . Informed, written consent was obtained from every patient, and the study methods met the tenets of the Declaration of Helsinki for medical research involving human subjects. The first patient was recruited on 4 September 2017.This prospective, randomized, double-blind trial was conducted in two obstetric departments of a secondary and a tertiary hospital. The study protocol was approved by the Institutional Review Board of the Medical University of Lublin (KE-0254/127/2017) and was prospectively registered at Only singleton pregnancy females, older than 18 years, scheduled for a cesarean section under spinal anesthesia could participate in the study. The exclusion criteria included a lack of informed consent, allergy to drugs used during the study, depression and epilepsy that required antidepressants or anticonvulsants, known coagulopathy as a contraindication for spinal anesthesia, addiction to alcohol or recreational drugs, and gestational age below 36 weeks.Each patient received single-shot spinal anesthesia with 0.5% hyperbaric bupivacaine  without an additional opioid. The bupivacaine solution was administered according to the patient’s height: from 1.8 mL for 150 cm individuals to 2.6 mL for 180 cm patients. At the end of the cesarean section, patients were randomly allocated to one of three groups (1:1:1 randomization): the QLB, TAPB, or control group (CON). The team member who anesthetized the patient opened an opaque envelope in which an allocation group was indicated. The envelope was sealed, and the patient allocation was prepared according to the randomization by a team member not directly involved in the process of anesthesia or further evaluation of the participants.The plane blocks were performed in the operating room before the transfer of patients to the ward. A curvilinear ultrasound probe was used to identify the truncal muscle and perform the QLB. In this group, a material wedge was placed under the patient’s back at the site of injection. The type 2 QLB  was performed in each case . To idenSonographic image of quadratus lumborum block before (A) and after (B) local anesthetic deposition. Yellow arrows denote needle shaft, and red arrows denote local anesthetic. EOM denotes external oblique muscle, IOM denotes internal oblique muscle, and QLM denotes quadratus lumborum muscle.In the postoperative care unit, pain treatment with a patient-controlled analgesia pump was initiated. A solution of morphine , 1 mg/mL, 1 mL per bolus with a lockout time of five minutes was administered. In the case of severe pain, more than 40 on the visual analog scale (VAS), an additional bolus of morphine (5 mg) could be administered at the midwife’s discretion. Moreover, each patient received intravenous paracetamol  every six hours.The primary outcome of this study determined acute pain intensity measured at rest and upon activity on the VAS (0 to 10 cm) at 2, 4, 8, 12, and 24 h after the cesarean section. Pain upon activity was measured during the abdominal muscle flexion, a trial of sitting up or raising the legs if the motor block vanished. The pain intensity was measured by an anesthesiologist who was not aware of the patient allocation (blinding).The other outcomes included morphine consumption during the first 24 h and chronic pain evaluation via the Neuropathic Pain Symptom Inventory (NPSI) developed by Bouhassira et al. . This inThe normality of the distribution was investigated for each continuous variable with the Shapiro–Wilk test. Normally distributed parameters were analyzed using an analysis of variance (ANOVA) method. These variables are presented as means with 95% confidence intervals. The Kruskal–Wallis test by ranks was used to compute parameters with non-normal distributions. A pairwise comparison was performed with the Mann–Whitney U test, and the Bonferroni correction was applied if the results of the Kruskal–Wallis test showed statistical significance. These data are presented as medians and interquartile ranges (IQR). Qualitative parameters were compared with the Fisher’s exact test. Logistic regression was used to reveal the parameters that affect chronic pain presentation, and the odds ratio (OR) was used to describe the predictors that were included in the model. The receiver operating characteristic (ROC) curve was calculated for the best model. All measurements were performed using Statistica 13.1 software . The randomization was also generated with Statistica software’s random number generator by a team member who was not directly involved in the process of recruiting, treating, and assessing patients.A preliminary study was performed to assess the sample size. The primary outcome of the study was the acute pain measurement on the VAS. The sample size analysis was calculated for the acute pain at hour 2. Thirty patients, 10 per group, were included with the mean VAS results 1, 1.5, and 2 in QLB, TAPB, and QLB, respectively. The calculated sample size for different means was 27 individuals for each group, with a root mean square standardized effect of 0.5, power 0.9, and alpha 0.05. We decided to randomize 105 participants into groups with 35 individuals in each group.The study was conducted from September 2017 to August 2019. Of the 128 patients assessed for eligibility, 105 were randomized and allocated to the intervention. A detailed description of the study participants is presented in the flowchart .CON denotes the control group, PCA denotes patient-controlled analgesia, QLB denotes the quadratus lumborum block group, and TAPB denotes the transversus abdominis plane block group.Patient demographic data and indications for cesarean delivery are shown in Of the five pain measurements at rest, a significant difference was found at a single time point . The paiAt three time points, a statistically significant difference was found upon activity . Lower pp < 0.001) (p < 0.001) than patients after the truncal blocks. No difference was found between the QLB and TAPB groups in postoperative pain severity and morphine consumption.Patients in the QLB and TAPB (9 mg IQR (5–10) and 10 mg (6–14)) groups used less morphine via PCA than participants in the CON group (16 mg (11–19); < 0.001) . MoreoveThe pain severity measured via the NPSI was significantly lower at months one and six in the QLB group than in the CON group . HoweverNo difference was detected between the QLB and TAPB groups. Moreover, no difference was found between the study groups in the number of patients who had any sign of chronic pain .p = 0.001). Conversely, subsequent cesarean section and fetal malpresentation decreased the risk of chronic pain prevalence at month six. The calculated OR was 0.225 , p < 0.01 for the previous cesarean delivery and 0.036 , p = 0.036 for fetal malpresentation. The area under the ROC curve for this model was 0.892.The factors associated with chronic pain occurrence after cesarean delivery included persistent pain severity at month three, previous cesarean section, and fetal malpresentation. Severe pain at month three increased the risk of chronic pain prevalence at month six , The results presented in the current study showed an alleviation of pain severity in patients after plane blocks in comparison with the CON group. Pain intensity upon activity was statistically decreased at two of the five time points in the TAPB group and three of the five measurements in the QLB group. However, at rest, the only significant difference was observed between patients after plane blocks and the CON group during a single pain evaluation. Moreover, patients in the QLB and TAPB groups used less morphine via PCA during the first postoperative day than participants in the CON group. In the current study, no difference was found between the TAPB and QLB groups in pain intensity or morphine consumption. The long-term evaluation showed a significant difference in chronic pain severity between the QLB and CON groups at months one and 6six However, according to the International Association for the Study of Pain, chronic pain can be recognized at least three months after surgery . MoreoveTo our knowledge, the only study that directly compared QLB with TAPB after cesarean section was conducted by Blanco et al. . In resuThe results of a recent metanalysis by El-Boghdadly et al. showed that both the QLB and the TAPB were superior to control in the absence of intrathecal morphine . HoweverSeveral trials have evaluated the efficacy of QLB analgesia after cesarean section, including QLB 1 , QLB 2 (posterior), and QLB 3 comparing the block with the control (sham or no block) ,13,14,15In our previous study, we assessed the prevalence and severity of chronic pain in patients who received QLB or TAPB after cesarean delivery . This obOnly a few studies have presented the alleviation of persistent postoperative pain due to regional anesthesia techniques ,21,22. IThe result of the logistic regression showed that three variables were associated with chronic pain prevalence in our trial. Only pain severity at month three increased the risk of chronic pain occurrence at month six. Both fetal malpresentation and subsequent cesarean section were associated with a lower prevalence of persistent pain. Our results are consistent with the findings presented by Niklasson et al. . The autAlthough our trial was preceded by a pilot study and power calculation was performed, still, a sample size could be not sufficient. In the study by McKeen et al. comparing the TAPB with controls in patients after the cesarean section, the mean NRS at hour 2 was 2.0 in the studied and 3.5 in the placebo group with a standard deviation of 2.3 . If the Our study had some limitations. Because QLB and TAPB were performed after the administration of spinal anesthesia, we did not test the block area with the pinprick technique. The study was conducted in two hospitals; therefore, truncal blocks were done by three anesthesiologists. We did not add any opioid spinally which could have affected pain severity after the procedure. Although statistical significance was detected for many parameters and the recruitment period was preceded by the power analysis, the number of analyzed patients was still limited. Despite the power calculation, our study could be underpowered regarding the primary outcome. The results of this study showed difference between the CON and the QLB groups in persistent pain severity; however, the median values of pain severity were relatively low.Our study showed that both truncal blocks reduced pain severity and total morphine consumption compared with the controls in patients after cesarean delivery. However, no difference in acute postoperative pain was observed between the QLB and TAPB groups. Moreover, patients in the QLB group had lower pain intensity than those in the CON group six months after surgery. It appears that the QLB might alleviate chronic postoperative pain severity in patients after cesarean section.


Mechanical neck pain (MNP) is a common health concern. Some studies suggested a relationship between neck pain and visual activity. We assessed the role of myopia as a contributing factor in the development of chronic MNP.  All medical students at Shiraz University School of Medicine, who were 18 to 22 years old, were invited to participate in this retrospective case-control study from March 2016 to March 2017. Numeric Pain Rating Scale (NPRS) was used to assess the average neck pain severity over the past 6 months in order to enroll participants as the case (≥3) or control (<3) groups. Demographic data and medical profile were obtained. After identifying eligible cases, we assigned age- and sex-matched controls, who also met the study criteria. Subsequently, participants completed the Neck Disability Index (NDI) and Neck Pain and Disability Scale (NPDS) questionnaires and were evaluated for myopia severity. Variables were compared between the case and control groups as well as within the case group. P-value<0.05 was considered statistically significant.  From over 700 medical students, around 150 cooperated. Eventually, 31 eligible cases (and 31 controls) were studied. NDI and NPDS were significantly higher in the case group (P<0.001). However, no significant differences were noticed between the groups regarding the severity (P=0.123) and the duration (P=0.417) of myopia. Also, the correlation of myopia severity with NDPS  and NDI  was non-significant within the case group. Our findings have not supported the influential role of myopia in the development of chronic MNP. It is estimated that over a third of billion people experience chronic neck pain annually . Neck paAll medical students at the Shiraz University of Medical Sciences, Shiraz, Iran, who aged 18 to 22 years old, were invited to participate in this retrospective case-control study. Recruitment was conducted from March 2016 to March 2017. Exclusion criteria consisted of using glasses or contact lenses while engaging in near-work activities, onset of myopia and neck pain within the past 6 months, other ophthalmological diseases except for myopia, history of refractive corrective surgeries, history of neck or head trauma, history of neurological, musculoskeletal or collagen vascular diseases (such as chronic pain syndrome), malignancy, psychiatric disorders including depression, and history of receiving medical, manual or surgical therapeutic modalities other than occasional over the counter or traditional analgesics. Participants were asked to rate their average neck pain severity over the past 6 months using the Numeric Pain Rating Scale (NPRS). Based on this score, they were allocated to either the case (NPRS≥3) or the control (NPRS<3) groups.et al. Authors considered these questionnaires to be superior due to their comprehensibility, internal consistency, easy administration, and suitability, as well as being time-saving for both patients and examiners [Demographic data, characteristics of neck pain, and relative information on the past medical history, onset of myopia, duration of near-work activities per day as well as other potentially influential factors were obtained. With the aim of eliminating confounding factors as much as possible and ensuring a homogenous population, further requirements were set; these included utilizing a desk and chair for reading/studying and working with a computer, complying with standard postures, and negative history of vigorous physical activities. After identifying eligible subjects for the case group, we assigned age- and sex-matched controls from the initial participants, who also met the study criteria. Subsequently, all participants completed the validated Persian Neck Disability Index (NDI) and the Neck Pain and Disability Scale (NPDS) questionnaires . In addixaminers .Informed consent was obtained from the participants and the confidentiality of patients’ information was preserved. The study protocol was in accordance with the Helsinki Declaration and approved by the institutional review board.Statistical analysis was performed using Windows SPSS software version 20 . Data are represented descriptively as frequency and mean ± standard deviation (SD), and odds ratio (OR) as applicable. Mann–Whitney U test was used to compare variables between the case and control groups. Also, the correlation of myopia severity with NDI and NPDS within the case group was examined using Spearman’s rho. All tests were two-sided and a P-value<0.05 was considered statistically significant.st year to 4th-year medical students were invited to participate in this study. Approximately, 150 filled out the data sheets, of whom 47 had NPRS≥3. Eventually, 31 students fulfilled the criteria of study and were allocated to the case group. This group consisted of 23 (74.2%) female and 8 (25.8%) male students with the mean age of 19.93±1.59 years  contributed to the neck/shoulder discomfort, external eye discomfort (related to dry-eye) did not have any significant adverse impact [et al examined the specific effect of eye-lens accommodation on trapezius muscle activity in 33 controls and 33 patients with neck pain, who also completed near-work viewing tasks using four distinct trial-lens. Trapezius muscle activity was not influenced by the lens accommodation alone. However, when there was incongruence between accommodation and convergence, a significant positive correlation was found between trapezius muscle activity and eye-lens accommodation, which subsequently leads to near-work-related neck discomfort [et al induced four levels of the oculomotor load in 28 subjects to study the trapezius muscle activity and reported that this parameter remained at a steady level in the absence of accommodative compensation. In contrast, a slope was observed when compensation occurred. Furthermore, the convergence response did not influence the electromyography of trapezius muscle [et al, which was conducted in a similar setting, investigated the impact of sustained oculomotor load on the static trapezius muscle activity in 28 subjects while staring at a viewing target (placed at a 5 diopter distance from the person’s near point of accommodation) through -3.5 and 0 diopter lenses for a duration of 5 minutes at each episode. The results showed that requiring a greater accommodative response induced a greater static trapezius muscle activity, which can consequently lead to trapezius muscle myalgia [et al found a weak correlation between the timing in alternate near-far lens accommodation through four different lenses and the trapezius muscle activity. He attributed this correlation to a possible connection between the ciliary and trapezius muscles as well as the need for a more stable head posture during challenging visual tasks [et al demonstrated that the movements of extra-ocular muscles in myopic patients result in a considerably different tonic activity of the trapezius and sternocleidomastoid muscles as compared to subjects with normal visual acuity. In myopic patients, the electromyography responses of neck muscles were not well-balanced [The present study aimed to explore the possible role of myopia in the development of chronic MNP among a population of young adults. Although NDPS and NDI scores were significantly higher in the case group, the duration and severity of myopia were not significantly different. This finding is contrary to our hypothesis. Also, the average duration of near-work activities per day, which could be a potentially confounding factor, show no statistical difference between the case and control groups. Pain measurements are generally subjective and pain sensitivity has a fundamental correlation with gender , 24. How ignored . In a moe impact . In a siscomfort . Richters muscle . Anotheral tasks . Valentibalanced . Richterbalanced . MNP is balanced . ObviousThe present study showed no correlation between impaired visual acuity and the development of chronic MNP in medical students. Nonetheless, the extent of consistent experimental findings on the impact of visual activities including accommodation, convergence, and extra-ocular muscles movements on the neck/shoulder discomfort cannot be ignored. In fact, these pieces of evidence seem to be sufficient to call upon further research for exploring their clinical significance.This article was extracted from the medical thesis written by Dr. Bahareh Kardeh, which was financially supported by the vice chancellor of research at Shiraz University of Medical Sciences, Shiraz, Iran (Grant No. 94-01-64-9905). The authors also thank the research consultation center of Shiraz University of Medical Sciences for proofreading this article.Authors declare that they have no conflicts of interest.


In the intensive care unit, patients are subject to discomforts and pain. Their management is essentially based on pharmacologic approaches. Immersive virtual reality could represent an adjunctive non-invasive and non-pharmacological pain control technique. It is based on real-time interaction with an artificial 360° immersive world using interfaces that enable physical and emotional perceptions to make the user feel better trying to reduce pain perception and to limit anxiety. Evaluation of virtual reality in intensive care unit is lacking and further studies are necessary before to introduce this alternative method for critical patients. In the intensive care unit (ICU), patients are subject to discomforts such as aggressive noises, lights, and pain which can be perceived as a hostile environment. Anxiety and discomfort generated by repeated medical cares and invasive procedures can induce cognitive disorders in critical illness survivors . Depress. Patients’ pain ratings during burn wound care significantly dropped when patients were distracted by immersive VR [versus standard care in 16 randomized controlled trials in acutely painful procedures although the strength of this finding was limited by clinical and statistical heterogeneity [According to the “gate control” theory , higher rsive VR . A meta-ogeneity .Although research on VR as a treatment intervention is on the rise, the literature on this topic in the adult ICU is quite sparse. In 2019, Blair et al. reported the case of a ventilated female on veno-venous extracorporeal membrane oxygenation (ECMO) placed under VR who subjectively reported decreased anxiety after each session  Gerber eTo the best of our knowledge, no studies have examined VR technology to improve ICU patients experience during painful procedures. The management of acute pain related to healthcare interventions remains a major global challenge. In our view, it will be interesting to assess the use of VR during acute painful procedures or chronic daily use in the ICU adult patients, without neurologic disorder, ventilated or not. We assume that reducing excessive pain may also reduce the stress experienced by the patient, the patient’s family and the health care givers. It will be interesting to evaluate if VR, by creating a distraction from unavoidable discomforts, can reduce anxiety and pain. Further clinical studies with standardized protocols and a well-trained professional team are required to assess feasibility and safety of this technique. The objective is to propose an immersive 360° visual experience that offers an opportunity for patients to be active in choosing experiences to relax their mind and their body: the patient decides which natural scenes (such as mountains or lakes) and background sounds he wants and how long each session would last to immerse himself in the experience. In terms of safety, it is important to study any side effects that may occur during a session: tolerance of the headset isolation, neurocognitive , or physical  effects and risk of cross infection between patients. The challenge for the future is to make VR accessible 24/7 to improve patients’ ICU experience and to introduce alternative methods for patients’ recovery.


Temporomandibular disorders (TMD) are considered as a heterogeneous group of psychophysiological disorders of the stomatognathic system . They arA prospective, quasi-experimental study, was performed. We include 16 patients with a diagnosis of temporomandibular joint dysfunction according to the Research Diagnostic Criteria for temporomandibular disorder. Patients were randomised into two groups: 8 (39.0 ± 13.2 years old) in the experimental group (EG) and 8 (39.8 ± 13.9 years old) in the control group (CG). Patients from both groups performed home-based exercises daily at home, GE patients performed 4 sessions of physiotherapy, having undergone condylar distraction techniques, CG patients did not perform any other type of intervention. All patients were evaluated before (T0) and after (T1) the intervention. The range of the mandible was evaluated through a digital calliper, the intensity of the pain through the numeric scale of the pain and the presence of articular noises, through palpation. All participants signed informed consent. The study was approved by the Ethics Committee of the Egas Monizp = .012) and decrease value of pain intensity in T1 when compared to T0 in the GE group (p = .008). The obtained results were analized using Student’s t test. There were no changes in joint noises when comparing T0 with T1 in both groups.Condylar distraction technique increased motion range values of the mandible from T0 to T1 in GE group (It is concluded that the condylar distraction technique has positive effects on pain and range of motion of the mandible. However, joint noises remained present after intervention, concluding that condylar distraction has no effect on noise reduction. Recent evidence suggests that manual therapy is a legitimate treatment for TMD promoting improvement in mouth opening and reduction in jaw pain . However


Persistent pain is a leading cause of disability worldwide yet implementation of clinical guidelines that recommend a biopsychosocial approach remains a challenge in clinical practise. Limited pain understanding amongst clinicians may be partly responsible for this.1) Qualitatively explore the experience of receiving PSE, understanding of PSE and operationalisation of PSE-related principles in routine clinical practice. 2) Quantitatively explore pain knowledge, attitudes, and behaviours of general practitioners (GPs) and nurse practitioners (NPs) before and after pain science education (PSE).An exploratory, single-site, mixed-methods study in north-east England. Fifteen NPs/GPs completed questionnaires and a case-vignette before and after a 70-min face-to-face PSE lecture. Qualitative data were thematically analysed from two focus groups after the intervention.Clinicians’ relatively high prior levels of knowledge, attitudes, and behaviour were similar after PSE. Qualitative themes described facilitation of self-reflection on pain management behaviours, and difficulties in operationalising PSE principles in practise including: limited patient rapport; short appointment times; patients’ passive and often oppositional biomedical treatment expectations; and clinicians’ lack of readily understandable language to communicate with patients.The findings highlight the value of PSE perceived by these clinicians who were already favourably inclined towards biopsychosocial pain management. They sought more resources for their personal learning and for communication with patients. Even with such favourable disposition, the practicalities and environment of clinical practice impeded the operationalisation of PSE-related principles.NCT04587596) in October 2020.This study was prospectively registered at ClinicalTrials.Gov (The online version contains supplementary material available at 10.1186/s12909-022-03265-2. What impact does a brief pain science education intervention have on knowledge, attitudes and behaviours in healthcare professionals at a GP surgery?What is the experience of receiving PSE and how does it affect operationalisation of the concepts?Pain management is frequently based on the biomedical model, rather than the guideline-consistent biopsychosocial model.Short pain science education interventions have been shown to be effective for improving students' and patients' pain knowledge, attitudes and behaviours.Clinicians with high prior levels of knowledge, attitudes and intention to treat in a guideline consistent way still value pain science education.The operationalisation of guideline consistent pain management is difficult due to the practicalities and environment of busy clinical practices.Barriers to guideline consistent pain management include patient expectation and difficulties conveying the evidence-base to patients.Pain is the most prevalent condition predisposing to disability worldwide . BiologiAn over reliance upon the biomedical approach to pain has been shown to be less successful, cost more and potentially it exacerbates pain and healthcare utilisation . It entaPatient perspectives on the barriers to effective pain management include HCP lack of ‘interest and empathy’; lack of GP specialised knowledge in pain management; lack of communication between HCPs; short consultation times with GPs and an absence of a multidisciplinary approach . A holisPain science education (PSE) is an evidence-based means of conveying pain education to patients, HCPs and students , 8. The Thus, PSE could be a useful brief intervention for time-limited clinicians as a form of continuing professional development (CPD) to facilitate an evidence-based approach to pain management. However, in the same way that PSE should be delivered in combination with other interventions within a clinical setting for patients, ideally PSE would be part of a broader package of CPD for health care professionals to enhance their approach to pain management . The aimIn this, exploratory, single-site, mixed-methods study, primary care professionals’ pain attitudes, knowledge and behaviour data were collected using two questionnaires and a case vignette pre and post-delivery of PSE. Additionally, data about the HCPs’ profession and age were collected. Qualitative data collected during two focus groups post intervention was thematically analysed. The philosophical approach applied to this mixed-methods study was pragmatism wherein the quantitative data and qualitative data provide context to one another particularly if dissonance between the quantitative and qualitative data should arise .Clinicians from a GP surgery in north-east England were invited to participate in the study during their usual monthly CPD session. GPs and NPs were invited by email from the practice manager to participate in the study. Data was collected in 2019. The GP surgery served approximately 19,300 patients. The patient age demographic for this GP surgery was similar to the national average. It is in the second lowest decile for the deprivation measurement scale. The GP surgery scored 2 on the deprivation measurement scale of 1–10 (one being the most deprived) .Explain Pain  . It is also observed to have adequate responsiveness to change .Participants were asked to consider a low back pain case vignette , and audio recorded and transcribed verbatim by JM. Field notes were also taken to facilitate contextualisation of the recordings. It is suggested that two to three focus groups identify 80% of the relevant themes .Given the exploratory nature of this study, descriptive rather than inferential statistical analysis was undertaken with quantitative data presented as mean (SD). The qualitative focus-group data was analysed using inductive reflexive thematic analysis . TranscrFifteen members of staff participated out of 19 eligible clinical staff members; four were nursing staff and 11 were GPs, all of whom gave informed consent to take part in this study. Of those 15 only nine completed questionnaires both pre and post intervention, five participants returned only pre-intervention surveys, and one returned only a post-intervention survey. The average age of participants was 46 years and there were 12 females and 3 males.Pain related knowledge and attitudes were similar before and after the PSE Table . ClinicaTen participants agreed to attend the semi-structured focus groups (six GPs and four NPs). Eight females and two males took part in two separate one hour focus groups. Two primary themes were identified. 1) difficulties of operationalising PSE principles and 2) clinician affinity for PSE but difficulty communicating it. Table There were consistent perceptions that patients had very passive and inappropriate beliefs about the way their pain should be managed.“…many of the ones we see they don’t really, they’re not interested in the mechanism of pain… They don’t seem to be interested in physiotherapy or anything they can do themselves.”They almost always expected and sometimes demanded pain medication, but it was felt that such a perspective had been to some extent ‘taught’ by the medical profession.“…it’s to do with expectation. It’s the way we’ve taught patients over the years. If they don’t leave with a prescription, they’re not happy.”aggressive, and they felt pressured to acquiesce to patient demands around medication.The expectation of patients for passive management rather than active, self-management of their pain resulted in difficult situations wherein clinicians sometimes felt that patients were “…just the other week I felt really intimidated by a patient so I prescribed some Diflam for him just to get rid of him because I felt quite threatened.”hard’ and a ‘fight’.Clinicians were aware that pain medication may not be helping the patient but they felt that the conversations they could have in the limited consultation time available made challenging a patient’s beliefs about medication ‘“They take this painkiller and it’s actually not helping their pain, it’s helping their addiction. So it’s, so that’s the kind of message but it’s difficult in 10 minutes you know to, to chat around it and so easy thing is to just give them painkillers.”“then you try to find a language to put it to the patient to see whether they will perceive it so I’ll start saying that the pain is possibly, you’re just feeding your addiction, this medication you’re taking is not actually helping your pain. They said you know I’m taking everything, maximum dose possible and I’m still in pain then you have to try to explain to them if that’s the case then why don’t you come off it. And maybe you’re just feeding your addiction.”Before clinicians are able to advise or direct a patient towards self-management they were having to alter existing patient beliefs about medication as noted in the quote above. Furthermore, one clinician requested that the environment in which they work was taken into context because it was a stressful one, featuring litigation, patients with mood disorders and comorbidities. Clinicians frequently termed their interactions over medication as a ‘fight’ which often led to non-guideline-consistent actions such as perpetuating prescribing or radiography.“For people (clinicians) who are stressed, who are already getting complaints elsewhere, to then have a conversation with someone who’s usually aggressive and difficult, that’s a big ask. And it’s not to say it’s not the right thing to do but actually to have that sort of conversation repeatedly. You know we do see a lot of chronic pain and to have that and to say no and to have to explain that and to have that fight, that’s exhausting and I think it’s easy when you’re not in the room to kind of legislate for things like this but the reality is quite different.”It was noted that clinician attempts to deprescribe are often not well received by patients sometimes leading to formal complaints:“It’s a bit like the poly-pharmacy and deprescribing. It’s not as straight forward as just taking the medication away. The number of complaints we get when pharmacists trying to be efficient remove drugs because they haven’t been used or change it over to something different, and then we get formal complaints…”“…if you do that (they’ll say) I’ll buy it on the street.”One clinician likened the patient expectation for analgesics to the persisting expectation for antibiotics. To which one GP responded as follows:“Explanation for anything is not good enough.”An NP followed this remark with:“You’ve got the fight on your hands.”Another GP’s response summed up the likely outcome of patient demand for analgesics as follows:“…but it’s difficult in 10 minutes you know to, to chat around it and so easy thing is to just give them painkillers.”One NP participant pointed out that in order to explain things like pain, clinicians needed to build rapport with patients first and this was difficult as GPs in the surgery no longer had an assigned patient list. GPs confirmed that patients would shop around for the GP most likely to give them medication. There was one report of a ‘rare’ patient who was keen to reduce his medications.Within this theme and linked closely to the theme above, there were subthemes including clinicians seeking more information to share with patients and the desire to learn more themselves. PSE led clinicians to think more about pain management and the factors involved.The limitations of the ten-minute appointment were frequently referred to as well as the benefits system. Participants noted that when benefits were reassessed there was a surge in consultations for pain.A GP referred to ‘sound bites’ and ‘reels’ he would like to learn to talk to his patients about pain. This was the HCP mode of operation when discussing any given condition, to have a set of information normally imparted. He felt that he lacked such a “reel” for persistent pain. Other clinicians referred to visuals and websites used in the intervention that they would like to access to aid patient PSE.“We tend to function on like a record, like if I think of contraception, there’s a reel that I use to tell patients about it but with pain I just haven’t got that yet.”Participants found the PSE lecture useful but a lot to digest in 70 min. A number suggested that they would like to revisit the information in “6–8 weeks” and another clinician suggested that it would take more than one session to change his practise.All participants felt that the PSE lecture was very relevant to them, many reported that it echoed existing information and presented new information. One GP suggested that the information was highly transferrable to any audience.“I think the session probably has relevance to everyone, it could be a layperson, it could be a doctor, because it’s a problem and it’s just how you engage with the session isn’t it? Depending on your background you might be more into one aspect or associate more with that.”This mixed-methods, study explored HCPs experience of receiving a one-off PSE CPD session and its, impact on pain understanding and daily practise.Clinicians demonstrated predominantly biopsychosocial understandings of pain at baseline, which were reinforced by the focus groups. However, the focus groups identified barriers to operationalising a guideline-consistent, biopsychosocial pain management approach and highlighted the strengths and limitations of the brief PSE intervention as a CPD tool.Baseline pain knowledge and attitudes were in keeping with existing literature for GPs and nurses after an education intervention or similar to attitudes in GPs at baseline –22. FurtExpectations’ for passive pain management in the form of medication reportedly dominated patient/surgery interactions relating to pain. Clinicians reported that demand for medication generally made them feel ‘intimidated’. This perception of patient expectation for medication and imaging is universal, increasingly prevalent and is global [Qualitative data found that the PSE intervention caused GPs and NPs to consider the obstacles to their real-life pain management. Furthermore, it led them to seek more information and aids to facilitate guideline-consistent management and operationalise their knowledge and attitudes. The prominent reason for non-guideline-consistent pain management was the breakdown of patient-centred, shared-decision-making. This was attributed to patient expectation and patients’ understanding of pain. ‘s global , 24.This study identified that guideline-consistent pain management is difficult to practise in a clinic in north-east England in spite of good knowledge and attitudes amongst HCPs. Obstacles include patients’ biomedical knowledge and attitudes about pain and expectations of pain management and limited appointment times. However, if time is limited then the ethical significance to ensure that the time is of good quality is even greater . ChallenPublic understanding of pain in this large patient catchment needs to be addressed. Successful strategies have included wide reaching public health campaigns to improve health literacy amongst the public . FurtherThis is a small, site-specific, exploratory study in a region where chronic pain co-exists with a diverse range of socio-economic factors therefore generalizability may be limited. However, it is an area where chronic pain is highly prevalent therefore the understanding of the challenges to good pain management in such areas is vital. The work was limited to staff working in GP practices and thus is not necessarily generalisable/transferable to other HCPs working in other contexts such as orthopaedic surgeons. Future work should be carried out to explore the impact and experience of PSE in other HCP groups. Similarly, this study only explored the impact and experience of receiving a brief PSE session delivered in a didactic fashion. The findings may have been different for a more comprehensive delivery of PSE or if PSE was delivered as part of a comprehensive CPD package for pain management.This study is not an RCT and thus the design does not permit cause and effect analysis. Furthermore, the sample size limits quantitative inference. Future, appropriately powered multi-centred mixed methods RCTs are needed to explore the impact of PSE for GP surgery staff on both clinician behaviours and patient outcomes. Such complex interventions based upon this exploratory study could be collaboratively undertaken with stakeholders to identify optimal methods of delivering PSE to HCPs.There was a brief dictaphone malfunction however field notes were taken throughout so that this did not result in the loss of any key information.Researcher background may influence data collection, analysis and interpretation. Three of the researchers  have experience of delivering PSE and are physiotherapists who deliver it regularly to either patients or students or both.The aims of this study were to explore the impacts of a one-off PSE lecture upon HCPs at a GP surgery and the experience of receiving PSE. Knowledge and attitudes were similar before and after a brief PSE session, which may have been due to a ceiling effect. HCPs valued the PSE and it facilitated reflection on practise. Despite a preference for guideline-consistent management, there were barriers to operationalising this approach. Barriers included limited patient rapport in a large and busy surgery, limited appointment times and patients with passive, biomedical treatment expectations. Clinicians seek skills to communicate PSE and management strategies with their patients. Future large scale studies are needed to explore if similar experiences exist in different regions to confirm these exploratory findings and in other clinical subgroups.Additional file 1. Supplemental Material.


Trigeminal neuralgia (TN) is a complex orofacial pain syndrome characterized by the paroxysmal onset of pain attacks in the trigeminal distribution. The underlying mechanism for this debilitating condition is still not clearly understood. Decades of basic and clinical evidence support the demyelination hypothesis, where demyelination along the trigeminal afferent pathway is a major driver for TN pathogenesis and pathophysiology. Such pathological demyelination can be triggered by physical compression of the trigeminal ganglion or another primary demyelinating disease, such as multiple sclerosis. Further examination of TN patients and animal models has revealed significant molecular changes, channelopathies, and electrophysiological abnormalities in the affected trigeminal nerve. Interestingly, recent electrophysiological recordings and advanced functional neuroimaging data have shed new light on the global structural changes and the altered connectivity in the central pain-related circuits in TN patients. The current article aims to review the latest findings on the pathophysiology of TN and cross-examining them with the current surgical and pharmacologic management for TN patients. Understanding the underlying biology of TN could help scientists and clinicians to identify novel targets and improve treatments for this complex, debilitating disease. Trigeminal neuralgia (TN), previously known as tic douloureux, is a chronic neuropathic pain syndrome characterized by recurrent unilateral lancinating facial pain limited to the distribution of the trigeminal nerve dermatome . It is aTraditionally, TN has been a clinical diagnosis, based on patient-reported symptoms . HoweverThe current article aims to review our current understanding of the basic mechanism of the disease and cross-examine these new data with the disease symptomatology and the current management strategies. Lastly, the outlook for future research and clinical practice will also be briefly discussed.The recurring, episodic, and unpredictable clinical course of TN makes it difficult to determine the exact incidence of the disease. The estimated incidence of TN ranges from 4.3 to 26.8 per 100,000 person-years, with a lifetime prevalence of 0.03% to 0.3% ,13. AlthTN can be debilitating because it causes a significant amount of pain in the orofacial region that is often disabling to the patient. The paroxysmal electric or stabbing pain attacks are transient and episodic, lasting less than 10 to 15 s ,18,19. TOne of the major reasons why TN is debilitating is that normal daily activities can trigger severe pain. The most frequent triggering factors were touching the face, talking, chewing, or brushing teeth ,10. AlthTN-related symptoms have been described in historical documents as early as in the sixteenth century . It was The rapid technological development of magnetic resonance imaging (MRI) has helped identify some of the appreciable anatomical changes in TN, which facilitated the new classification scheme . High-reIn addition to the IHS and IASP classifications, other groups also independently published classifications of TN-related facial pain. For example, Burchiel and colleagues classified facial pain syndromes into seven categories to help develop a framework to better diagnose and treat different types of TN based on the pain characteristic or the inciting event. Burchiel’s classification includes TN type I , TN type II , TN due to injury , TN secondary to multiple sclerosis, infection-related postherpetic TN, and atypical somatoform facial pain ,35. ThisClassical TN is defined by focal neurovascular compression of the trigeminal nerve structure, usually occurring at the junction of the peripheral trigeminal nerve and root by vasculatures at the prepontine cistern within the Meckel’s cave ,36. WhilHistological examinations of the trigeminal nerve in classical TN patients have provided clues on the pathogenesis of the disease. Compression of the trigeminal nerve is associated with a significant level of myelin erosion and disintegration from inflammation, particularly at the nerve indentation area ,44,45,46Subsequently, these compression-related structural changes trigger several crucial downstream effects that play an important role in developing TN symptoms. Dysregulation of voltage-gated sodium (Nav) channels is functionally linked to TN . Both prIn contrast, downregulation of Nav1.7 in the trigeminal nerve root is found in TN patients and preclinical TN models ,59,60. NThe channelopathies and pathologic changes in the architectures of afferent neurons subsequently result in functional hyperexcitability of the trigeminal nerve observed in TN. Indeed, recording of trigeminal nerve roots in models of classical TN demonstrated ectopic generations of action potentials and prolonged after-discharges in demyelinated neurons ,71,72,73Although neurovascular compression accounts for most TN cases, primary demyelination disorders, such as multiple sclerosis, can also lead to TN symptoms. It has been well documented that patients with MS are at a higher risk of developing neuropathic pain and are estimated to be twenty times more likely to develop TN than the general population ,80. PathHowever, it has also been speculated that central demyelinating lesions can also independently lead to TN. Intrapontine demyelination along the trigeminal afferent and the trigeminal nucleus has been associated with TN symptoms in patients with MS or a brainstem infarction ,88,89,90Central sensitization is a process through which the nociceptive system becomes hyperexcitable or a state of hyperexcitability, and it has been implicated in various chronic pain conditions ,94. WithAmplified nociceptive signal transmission is found in TN patients. In a series of electrophysiological recordings in TN patients with concomitant chronic facial pain, Obermann and colleagues demonstrated that pain-related evoked potentials are significantly augmented in all trigeminal divisions on both symptomatic and non-symptomatic sides . This fiFunctional imaging data in TN patients has also helped further delineate the involvement of pain-related supraspinal structures. Unsurprisingly, painful attacks in TN patients lead to increased activity in the trigeminal nuclei, thalamus, and somatosensory cortices—areas that are classically associated with pain-related sensory processing . MoreoveAnticonvulsant medications form the mainstay of medical therapies for TN. Of these, the best evidence exists for carbamazepine, which has been found to be effective in multiple randomized controlled trials ,102,103.If the first-line anticonvulsants are ineffective or poorly tolerated, other anticonvulsive agents, including lamotrigine, gabapentin, and pregabalin, can also be considered as second agents or as monotherapy . LamotriClostridium botulinum, is an effective maintenance treatment for TN [Trigger point injections have also been explored as a maintenance strategy. For example, when used in conjunction with gabapentin, injection of ropivacaine, a local anesthetic, into facial TN pain trigger points has been shown to provide lasting pain relief for at least 28 days . Multiplt for TN ,111,112.t for TN . Single t for TN . HoweverLastly, manual acupuncture and electroacupuncture, based on traditional Chinese medicine concepts, could be effective adjunct therapies for TN . It was In addition to maintenance therapies, other drugs have been studied for use as abortive treatment during acute pain attacks. An intranasal spray of 8% lidocaine has also shown statistically significant pain reduction for four hours in patients with second-division TN . IntraveMicrovascular decompression (MVD) is considered the first-line surgical procedure for patients with clear neurovascular compression etiology determined by imaging ,123. It For those without neurovascular compressions, particularly when MVD is initially intended but compression is not observed intraoperatively, open interfascicular neurolysis can be considered . This teAdditional to the open surgical approaches, minimally invasive stereotactic radiosurgery (SRS), such as Gamma Knife and Cyberknife, which involves the application of ionizing radiation to the trigeminal nerve, is a viable alternative therapeutic option for TN. The exact mechanism of pain relief in SRS is unknown. Still, it is thought that targeted ionizing radiation damages sodium channels on the trigeminal fiber, which interrupts afferent sensory transmission . AlthougWhen a patient cannot tolerate neurological surgery or presents without underlying vascular compression, percutaneous interventions can be offered. These techniques can be subclassified into radiofrequency thermal ablation, balloon compression, and chemical rhizotomy.Percutaneous thermal rhizotomy with radiofrequency ablation (RFA) was first introduced by Sweet and colleagues. They hypothesized that carefully graded increments of heat could selectively damage smaller myelinated and unmyelinated fibers that are responsible for pain transmission, since the non-nociceptive A-beta fibers are relatively protected from heat due to their heavier myelin sheaths . They rePercutaneous balloon compression (PBC) is another technique that aims to treat TN by lesioning afferent fibers at the level of the Gasserian ganglion. A recent retrospective study suggested a first-time success rate of 89% after PBC, with 76% of patients able to titrate off pain medicines . Data frLastly, percutaneous glycerol rhizotomy relies on the chemical ablation of pain-transducing nerve fibers. It carries a similar success rate to other percutaneous techniques but can have a recurrence rate of up to 50% by three years post-procedure . SimilarIn the past three decades, significant progress has been made to understand the pathophysiology of TN. The demyelination-induced trigeminal hyperexcitability theory has offered a critical mechanistic basis for the diagnosis and the implementation of current medical therapies , surgical procedures , and percutaneous techniques  for TN. However, several crucial observations related to disease classification, diagnosis, and treatment efficacy have left some aspects in the current explanation of TN pathophysiology rather unsatisfying.It has been increasingly recognized that TN’s etiology is likely multifactorial in many patients. Only a small percentage of TN patients present with demonstrable compression or morphological changes in the trigeminal nerve, and neurovascular compression does not always translate to disease ,148,149.Therefore, the lack of complete understanding of TN’s complex etiology, pathogenesis, and pathophysiology poses a challenge for clinicians and basic scientists in discovering targeted therapies for patients. Future studies focusing on investigating the basic mechanism for TN, such as genetics, molecular biology, electrophysiology, and functional imaging could further improve the precision of diagnosis and therapies for patients suffering from this debilitating disease.


Studies have shown that spinal cord stimulation (SCS) therapy is effective in the management of chronic low back pain. It plays a role by minimizing the intensity of chronic pain, improving the quality of life index, reducing the intake of narcotic analgesics, and increasing the functional improvement in the working environment. However, spinal cord stimulation therapy is not universal because of the complications in the procedure itself, the invasive nature of the treatment, and cost-effectiveness. Therefore, the proper selection of the patients is necessary to get the maximum benefit from the treatment. The study's main objective is to determine the role of spinal cord stimulation in treating non-surgical patients with chronic low back pain. The article will review the mechanism, outcomes, efficacy, predisposing factors in the success and failure of the treatment and indications, contraindications, and selection of patients undergoing spinal cord stimulation therapy. A manual search of the literature was done using databases like Google Scholar and PubMed using the keywords: spinal cord, stimulation, chronic, and low back pain. A total of 37 articles were included in the study after considering the inclusion and exclusion criteria. Spinal cord stimulation therapy effectively treats refractory lower back pain, considering the technology and mechanism of action. The authors conclude that spinal cord stimulation therapy can be used to manage chronic low back pain, other neuropathic pain, and ischemic pain when other standard treatment methods have failed and the pain persisted for more than six months. Chronic lower back pain is a common comorbidity worldwide and the fifth most common in the United States . In the The gate theory of pain proposed by Melzac and Wall in 1965 stated that the large myelinated nerve fibers in the dorsal column inhibit the transmission of impulses to the smaller and unmyelinated afferent nerves in the spinal cord . ExperimSCS has been used widely for chronic back pain over pharmacological or surgical treatments, as it has shown favorable outcomes. Many studies and trials have shown the promising results of SCS in improving chronic lower back pain . EfficieA systematic search was carried out of the literature and relevant articles in databases like Google Scholar, PubMed Central, and Web of Science. The keywords used to search the articles were spinal cord, stimulation, and low back pain. We prepared a separate Microsoft Excel sheet  of the searched literature and did the initial screening by reviewing our inclusion and exclusion criteria. The included patients were more than 18 years old, with symptoms of lower back pain of more than six months and without a history of surgical treatment. In addition, patients with previous surgical treatment, patients with psychiatric illness who are not in a state of evaluating the treatment outcome, and patients with mechanical instability were excluded from the study. The articles that met the exclusion article during the screening and the duplicates were removed. A total of 37 articles were included, and we reached a consensus with a discussion with a third independent author.Mechanism of pain relief using SCSSpinal cord stimulation (SCS), previously also known as dorsal column stimulation, is mechanistically based on "gate control theory for pain transmission" . In 1965Application of electrical stimulation activates the dorsal column, which leads to pain inhibition, the primary mechanism of conventional (tonic) SCS -11. It lThus, the mechanism of SCS therapy depends on the gate control theory where the noxious stimulus stimulates the smaller fibers to cause the pain, and the large diameter somatosensory fibers lead to the inhibition of the transmission of the pain signals forming collaterals in the dorsal horn after activation. Different anatomical locations like distal to the dorsal root ganglion, dorsal root ganglion, and supraspinal structures are used to place the electrodes for electrical stimulation of the spinal cord.Outcome of spinal cord stimulation therapyChronic lower back pain is a disorder that affects all aspects of the individuals' life afflicted by it. In treating lower back pain in non-surgical patients, spinal cord stimulation has been a well-established treatment option . Our stuIn the study by Chapman et al. in 17 patients, the ODI score improved from 67.7 ± 14.2 at baseline to a mean of 18.8 ± 11.5 after one month of treatment and 10.0% ± 8.4 after six months of treatment. The EQ-5D index increased from a mean of 0.30 ± 0.16 to a mean of 0.85 ± 0.10 after one month and 0.86 ± 0.07 after six months of treatment . ImproveThus, the primary and secondary outcomes in the patients after SCS therapy in the different studies show that it is effective in treating patients with lower back pain in non-surgical patients. The primary and secondary outcomes of the spinal cord stimulation therapy in different clinical trials are shown in Table Clinical efficacy and cost-effectivenessChronic low back pain has been the major leading cause of disability worldwide and has impaired the QoL for the past several years. Therefore, there is a huge necessity for improving treatment options for those living with that problem and improving their quality of life . SCS theGreat patient satisfaction was reported in 88% and even 12% return to their work who undergone SCS treatment, and subjects treated with 10 kHz SCS therapy has improved disability outcomes -29. The Hence, SCS therapy has greater efficacy in controlling chronic pain and improving quality of life. In addition, SCS proves to be cost-effective, as it is less expensive than surgical treatment because once the electrodes are implanted, the cost-utility decreases significantly. Hence, it would be more appropriate in the long term, as the benefit of SCS therapy is much cheaper and effective than other treatment modalities in patients with chronic lower back pain.Predisposing factors in predicting the success or failure of SCSSeveral factors play a role in determining whether spinal cord stimulation will be a success or not in treating low back pain. Identifying these factors could help with appropriate patient selection for this invasive procedure and those patients who can benefit the most from this procedure. In the study by Ondonkor et al., it was analyzed that various factors determine the success or failure of spinal cord stimulation . SuccessA retrospective cohort by Cruz et al. shows a significant correlation between smoking (p = 0.017) and recreational/illegal drug use (p = 0.045) with early failure of SCS . The patBased on the above information, it can be concluded that the success and failure of spinal cord stimulation therapy depend upon factors like age and different types of stimulator waveform. The other factors include comorbidities, use of oral analgesics, smoking, characteristics and duration of pain, and the number of leads used for the stimulation.Indications, contraindications, and selection of a patient for spinal cord stimulation therapySpinal cord stimulation therapy can be used to manage chronic low back pain, other neuropathic pain, and ischemic pain when other standard treatment methods have failed and the pain persisted for more than six months -36. AccoThere are contraindications where SCS therapy can't be used, like in patients with a bleeding disorder, patients on anticoagulation therapy, and systemic or local sepsis ,38. PatiPatients selected should understand the process, expense, and invasive nature of therapy . So, durTo properly select patients for SCS therapy, the indications and contraindications should be determined carefully with the help group of treating physicians to reduce the harmful effects on the patients and draw the maximum benefits. Proper selection of patients minimizes the unnecessary invasive intervention and maximizes the chance of good outcomes.In the past four decades, SCS therapy has achieved good results in reducing the pain of patients with chronic low back pain and improving the functional status of patients. In addition, this type of treatment has shown great promise in treating patients who are not eligible for surgery. However, the increasing prevalence and economic burden should be addressed appropriately to make it easier for patients to obtain SCS treatment. Furthermore, spinal cord stimulation may significantly affect refractory low back pain treatment and benefit clinically considering its technology and mechanism of action. Thus, this therapy will occupy a special place in future, multidisciplinary neuropathic pain management.