Objective. To evaluate the usefulness of the pain tracking technique in acute mechanical low back pain. Method. We performed an experimental prospective  explanatory study between January 2011 and September 2012. The sample was randomly divided into two groups. Patients were assessed at the start and end of the treatment using the visual analogue scale and the Waddell test. Treatment consisted in applying the pain tracking technique to the study group and interferential current therapy to the control group. At the end of treatment, cryotherapy was applied for 10 minutes. The Wilcoxon signed-rank test and the Mann Whitney test were used. They were performed with a predetermined significance level of p ≤ 0.05. Results. Pain was triggered by prolonged static posture and intense physical labor and intensified through trunk movements and when sitting and standing. The greatest relief was reported in lateral decubitus position and in William's position. The majority of the patients had contracture. Pain and disability were modified with the rehabilitation treatment in both groups. Conclusions. Both the pain tracking and interferential current techniques combined with cryotherapy are useful treatments for acute mechanical low back pain. The onset of analgesia is faster when using the pain tracking technique. Low back pain is a common ailment, so much so that it is estimated that 80% of the population will suffer from it at some point in their lives –6.It is thought that 30% of adolescents have experienced at least one episode of low back pain. However, first episodes most frequently present themselves in adults aged between 20 and 40, dropping in middle age, just when X-ray and imaging alterations become more evident. This supports the hypothesis that casts doubt on the relationship between disc lesions and low back pain, with or without pain radiation .Low back pain is the second leading cause for GP consultations, the fifth for hospitalisation, and the third for surgical intervention of the musculoskeletal disorders. It is the third cause of chronic functional disability, after respiratory complaints and trauma. It has been found that low back pain has a high prevalence, independently of the socioeconomic status of a given population , 9.It can be characterised by presenting low back pain in the vertebral or paravertebral region, with radiation to the gluteal region and down to the middle third of the rear of both thighs. It increases through physical activity and certain movements and is relieved through rest and certain antalgic positions. It does not wake the patient during the night. Frequently, there is a trigger, there have been previous episodes, and there are no associated symptoms. This pain generally corresponds to a structural alteration or functional-postural overloading of the elements that make up the lumbar spine, namely, the vertebral body, ligaments, intervertebral discs, and paravertebral muscles, meaning that aetiological diagnosis is only possible in a small percentage of cases. It is also the reason why the majority of instances of low back pain of this kind fall into the category of nonspecific low back pain .Prevention is one of the fundamental aspects in the treatment of low back pain, with a view to limiting its serious socioeconomic repercussions. It is based on three central pillars: postural hygiene, exercises, and lifting weights in inadequate postural positions , 11. BacAs regards traction, a Spanish work group concluded that the effectiveness of traction is unknown (level D evidence) and in fact proved no more effective than the placebo (level C evidence) , 13.There are very few meta-analyses or controlled clinical trials into the usefulness of physical agents in low back pain –18. AmonCurrent practice sees ice recommended during the first 72 hours, though there is insufficient evidence of its effects in patients with acute or subacute pain , 20.The use of laser has been studied, concluding that no study has been carried out to evaluate its use in the treatment of low back pain .The above measures provide satisfactory relief to a large number of patients. However, there remains a group that reports no pain relief .Electrotherapy is considered among the noninvasive pain treatment techniques, in both its low- and medium-voltage applications , 18.Deep oscillation therapy is an effective technique for pain relief and has the advantage of being deep-acting and achieved with minimal mechanical impact, meaning it is useful in acute pain processes , 25.Medium-voltage electrotherapy, like interferential current therapy, combined with ultrasound with zeroed out parameters, together known as pain tracking, is applied in order to diagnose or locate the trigger points. It has therapeutic and prognostic value, enabling detection of significant changes from one session to the next, and has demonstrated positive results in the immediate relief of acute radicular and neurogenic pain, as well as somatic pain , 18. TheWe performed an experimental prospective  explanatory study between January 2011 and September 2012.The universe was made up of all those patients referred to the Physical Medicine and Rehabilitation Clinic at the Clinical Research Center with clinically diagnosed acute mechanical low back pain. The sample was made up of 90 patients who expressed a desire to participate in the study and whose low back pain had begun no more than 7 days ago, presenting neither radiation to the lower body parts nor decompensation. Defectual psychiatric and psychotic patients were excluded from the study as were those whose state of health prevented them from participating or where medical treatment was indicated. All patients were interviewed and physically examined by palpation of the paravertebral region, checking for contracture and pain in the spinous processes of the lumbar vertebrae in order to diagnose minor intervertebral derangement (MID). A medical history was taken, including sociodemographic and epidemiological characteristics, and the visual analogue scale (VAS) and Foral Waddell test were applied before and after treatment with physical agents.The sample was divided into 2 groups, where Group I, or the study group, corresponded to even numbers and Group II, or the control group, to odd numbers. By way of treatment plan, patients received daily treatment over 7 sessions.The study group was treated using the pain tracking technique with interferential current applied to the lumbosacral spine region, with amplitude modulation frequency (AMF) of 100 Hz, spectrum of 0 Hz, carrier frequency of 4000 Hz, and ultrasound with zeroed out parameters. The positive electrode was used as the indifferent electrode and positioned on the metamera itself or nearby target area, while the negative electrode was substituted for the ultrasound applicator and moved slowly over the target area. Treatment began at the lowest intensity, increasing progressively until reaching the limit of tolerance. The patient was put in ventral decubitus (prone) position with a pillow under the abdomen.Group II, or the control group, received treatment with interferential current and cryotherapy. The patient was put in the lateral or ventral decubitus (prone) position with a pillow under the abdomen to correct lumbar lordosis. Interferential current was applied using the tetrapolar method to the lumbosacral spine region, with carrier frequency of 4000 Hz, AMF of 100 Hz, spectrum of 50 Hz, with spectrum variance 6/6, for 10 minutes.We used PHYSIOMED's IONOSON-Expert device for both groups.After the electrotherapy, in both groups we applied 10 minutes of cryotherapy with a clockwise massage over the 7 treatment sessions. Both groups were issued with postural hygiene recommendations at home.In terms of the professions of our patients, 27 are labourers, 17 are professionals, 11 are housewives, and 10 are drivers. The remainder are office workers or students.In the study, pain was triggered by prolonged static posture in the workplace for 31 patients, intense physical labour for 26 patients, bending and twisting and forward trunk bending for 15 and 12, respectively, and 6 through carrying out work with vibrations. We found that patients worsened sitting in 23 cases, with trunk movements in 22 and standing in 18. In terms of postures that provided relief, the lateral decubitus position was reported by 54 patients as being effective, the Williams position by 29 patients, and the ventral decubitus (prone) position by 7 patients.Some 83.3% of the patients had contracture and minor intervertebral derangement (MID) was detected in the physical examination of 26 patients.Evaluation Criteria. Pain was evaluated according to its intensity using the visual analogue scale by assigning it a score:No pain = 0.Slight pain = 1–3.Moderate pain = 4–6.Intense pain = 7–10.No disability = 0.Slight disability = 1–3.Moderate disability = 4–6.Severe disability = 7–9.For the evaluation of the Foral Waddell test, we used the following scale:A medical history was taken for each patient. A database was created to process these medical histories using descriptive techniques (median). The results are expressed in tables.To establish a comparison between the pain variables, the Wilcoxon signed-rank test and the disability test were applied to both groups before and after treatment, and the Mann Whitney test was used to compare the onset of analgesia also in both groups.p ≤ 0.05.The tests were performed with a predetermined significance level of p = 0.597. At the end of treatment, the median VAS score was 0.00 in Group I and 1.00 in Group II with p < 0.037, with significant differences between the two groups, meaning that both treatments were effective in the treatment of acute mechanical low back pain.p < 0.001.When we compared the pain based on its clinical evolution from start to end of treatment, we observed highly significant differences in the two groups with p = 0.823, while, in the control group, the median was 5.00 at the start of treatment and 0.00 by the end of treatment with p = 0.131, with no significant differences between the groups. When we compared the test at the start and end of treatment by groups, we observed highly significant differences in the two groups with p < 0.001.p < 0.001, where pain relief was faster among the patients who were treated using the pain tracking technique  search terms were “pain tracking.”Hoek 1972) indicates that the incidence of occupational disability through back pain increased from 2.9% in 1959 to 61% in 1968 in the Dutch population. Nachelsom (1992) estimates a rise within the Swedish population from 3% in 1980 to 8% in 1990 and of 25 days absent from work in 1983 to 30 days in 1985 and 40 days in 1990. Waddell (1987) reports an increase within the Canadian population from 2.17% in 1953 to 5.46% in 1998. Uy tlendael (1981) reports an increase within the Belgian population from 0.4% in 1971 to 3.6% in 1978. It is observed that while the rate of low back pain has risen arithmetically, the rate of disability resulting from back pain has risen geometrically  indicate.Low back pain renders the patient unable to carry out certain activities. However, this disability is significantly modified when the pain is relieved, and the patient is able to resume those activities they had had to stop with the onset of the pain.Both the pain tracking and interferential current techniques combined with cryotherapy are useful treatments for acute mechanical low back pain.The onset of analgesia is faster when using the pain tracking technique.


Of the patients with no relief, 81.1% (n = 30) were found to have extra-articular pathology as the cause of their pain and the remainder are under on-going investigation. Intra-articular hip injection is an important investigation in the diagnostic pathway of young adult hip pain, as it can highlight and differentiate those patients with referred pain from extra-articular pathology. This benefit may be further enhanced if injections are performed in theatres using image intensifier, under sedation, as it allows direct penetration into the joint without any local anaesthetic infiltration of surrounding tissue. The latter allows immediate objective assessment of symptom relief, eliminating the need to rely on retrospective patient recall of symptom change.Hip pain in young adults is not always caused by intra-articular pathology, even in the presence of abnormal examination and imaging findings. Therefore, management of young adult hip pain requires processes that identify patients who are likely to benefit from surgical intervention. An important investigation in the diagnostic pathway is the intra-articular injection; a negative response to this should alert the surgeon to the presence of symptomatic extra-articular causes of hip pain. Our aim was to identify the proportion of patients referred with intra-articular pathology whose primary cause of pain was of extra-articular origin. A total of 143 intra-articular hip injections  were performed over a 2-year period. Mean patient age was 41.95  years with a mean body mass index of 27 ; 26% of patients ( The young adult presenting with hip pain often reports relatively non-specific symptoms and on physical examination, can be difficult to elucidate the precise driver of their pain as innervation is broad and ill-defined. Consequently, patients are unable to pinpoint the exact location of their symptoms due to referred pain, and therefore, the aetiology of the pain cannot always be clear .In patients with no significant arthritic change on plain weight bearing radiographs, we typically investigate further with computed tomography and magnetic resonance imaging (MRI) scans  and 2. AFor over half a century, intra-articular injection of corticosteroid has been used by orthopaedic surgeons and rheumatologists to provide symptomatic relief . In addiIt could be said that it is more important to a surgeon if a patient has pathology on diagnostic imaging but gains no relief from the injection. This indicates to the surgeon that the pathology identified on the patients’ imaging is incidental, therefore ensuring that the surgeon does not perform an unnecessary operation by not treating the root cause of their pain. Furthermore, it ensures that other avenues are explored to establish the true cause of a patient’s symptoms.To identify the proportion of patients referred with intra-articular pathology whose primary cause of pain was of extra-articular origin.Using Bluespier  we searched for all intra-articular injections of LA and corticosteroid into the hip performed between April 2012 and April 2014 undertaken by a single orthopaedic surgeon with a specialist interest in young adult hip surgery. Using an audit tool, the following information was recorded on all patients: age; body mass index (BMI); whether they gained pain relief; duration of pain relief; complications; further investigation results and management. Confidence intervals (CIs) of the means were performed using GraphPad  Statistics software.This work was registered with the audit department at The EOC, Epsom, Surrey, UK.Between April 2012 and April 2014, a total of 143 intra-articular hip injections of LA and corticosteroid were performed either under ultrasound guidance (120) or in theatre using an image intensifier (23). The mean age of the group was 41.95 (95% CI: 39.50–44.41) years with a mean BMI of 27 (95% CI: 25.77–28.23). Complete pain relief was seen in 104 (72%) patients, lasting an average of 5.0 weeks (95% CI: 4.15–5.89). Out of our cohort, three different complications were noted: one infected joint (ultrasound guided), two transient femoral nerve palsies (ultrasound guided) and five significant steroid flares.n = 14), greater trochanteric pain syndrome (GTPS) radiating to the groin (n = 8), inguinal hernias (n = 2), rectus avulsions (n = 1), osteitis pubis (n = 1), neurological (n = 1), urological (n = 1) and gynaecological (n = 2) diagnoses. Seven patients who did not gain relief from the investigation are still under investigation; these injections were performed under ultrasound guidance and the patients are awaiting repeat injections in theatre as no further pathology has been found.No relief from the injection was seen in 37 [26% (95% CI: 19.37–33.64)] patients, 31 of those having undergone injection under ultrasound guidance , which are predominantly seen in athletes. These can present similarly to labral tears, whereby the patient undergoes a traumatic event and experiences anterior thigh pain and a limitation in range of movement caused by pain inhibition. The management of this pathology is clearly different, and it is therefore critical to establish the true cause of pain at an early stage .Both inguinal and femoral herniae are causes of groin pain and as such should be considered in the differential diagnosis of those presenting with diffuse groin pain . FurtherThis study aimed to establish whether the intra-articular hip injection is a useful diagnostic tool to aid the management of ‘hip or groin pain’. We believe that the ability to establish whether pain generators are intra- or extra-articular is critical in the appropriate management of these patients. The study’s retrospective nature enabled us to review our current practice, allowing us to establish whether this additional information is affecting our management. Our data have shown that approximately a quarter of our patients who had labral tears did not respond to the injection and as such are not suitable candidates for hip arthroscopy to treat the cause, in most cases femoroacetabular impingement.Our data show a strong negative predictive value of 0.81 for patients who do not respond to treatment. Although this is a significant number in itself, the true value might be even higher as our definition of false negatives might have underestimated the predictive power of this diagnostic test. The reason for this is that these patients had their injections under ultrasound guidance and are awaiting repeat injections in theatres. If they are found to have relief from the repeat injection, then there may have been inadequate penetration into the joint, which can have acted as a confounding factor in this context.However, there are risks and side effects relating to the intra-articular injection. Firstly, there is a small but significant risk of intra-articular sepsis, which has been demonstrated in the complications of our cohort. Furthermore, a steroid flare, whereby there is crystallisation of the steroid within the joint, can result in worsening hip pain for up to a week following the injection and can lead to significant morbidity. However, the risks involved in undergoing an intra-articular hip injection are certainly outweighed by those related to operative treatment, especially in cases where it has been found that such treatment would be of no benefit to the patient.There are benefits to performing the injections under sedation in theatre. After performing an arthrogram , the surIn conclusion, hip-type pain in young adults is not always caused by intra-articular pathology even in the presence of abnormalities on examination and/or imaging. An important investigation in the diagnostic pathway is the intra-articular injection. A negative response to intra-articular injection should alert the surgeon to the presence of symptomatic extra-articular causes of hip pain, therefore avoiding unnecessary surgery, its inherent risk and any delays in the treatment of the true pain generator.Elective Orthopaedic Centre, Epsom (EOC).The None declared.


Background: Energy medicine (EM) derives from the theory that a subtle biologic energy can be influenced for therapeutic effect. EM practitioners may be trained within a specific tradition or work solo. Few studies have investigated the feasibility of solo-practitioner EM in hospitals.Objective: This study investigated the feasibility of EM as provided by a solo practitioner in inpatient and emergent settings.Design: Feasibility study, including a prospective case series.Settings: Inpatient units and emergency department.Outcome measures: To investigate the feasibility of EM, acceptability, demand, implementation, and practicality were assessed. Short-term clinical changes were documented by treating physicians.Participants: Patients, employees, and family members were enrolled in the study only if study physicians expected no or slow improvement in specific symptoms. Those with secondary gains or who could not communicate perception of symptom change were excluded.Results: EM was found to have acceptability and demand, and implementation was smooth because study procedures dovetailed with conventional clinical practice. Practicality was acceptable within the study but was low upon further application of EM because of cost of program administration. Twenty-four of 32 patients requested relief from pain. Of 50 reports of pain, 5 (10%) showed no improvement; 4 (8%), slight improvement; 3 (6%), moderate improvement; and 38 (76%), marked improvement. Twenty-one patients had issues other than pain. Of 29 non–pain-related problems, 3 (10%) showed no, 2 (7%) showed slight, 1 (4%) showed moderate, and 23 (79%) showed marked improvement. Changes during EM sessions were usually immediate.Conclusions: This study successfully implemented EM provided by a solo practitioner in inpatient and emergent hospital settings and found that acceptability and demand justified its presence. Most patients experienced marked, immediate improvement of symptoms associated with their chief complaint. Substantial practicality issues must be addressed to implement EM clinically in a hospital, however. The National Institutes of Health includes energy healing therapy in its list of popular complementary and alternative medicine (CAM) methods.4E5 cancer outcomes,7 fatigue, mood,2 fibromyalgia, phantom limb pain, and carpal tunnel syndrome.8 No report was found in the published literature of increased mortality, morbidity,8 or serious adverse effects,1 although some caution in patient selection is advisable.9Practitioners of EM treat the patient in close proximity  as well as at a distance (from a different room or even a different time zone). Studies have shown EM to improve pain, anxiety, wound healing, functional status, blood pressure, immune function, relaxation, well-being,10 and EM is increasingly being offered to both inpatients and outpatients by major hospitals. The growth and acceptance of EM have resulted largely from patient satisfaction, with some surveys reporting the percentage of “satisfied users” as high as 98%.11Even though mechanisms of EM have not yet been established in terms of biomedical science, theories have been advanced,13 but few have explored how solo practitioners (those unaffiliated with a particular system of EM) can feasibly be integrated into clinical care.Many forms of energy medicine are practiced by trained practitioners within specific traditions, such as Reiki, Healing Touch, and Therapeutic Touch. In addition, however, some solo practitioners discover their ability to effect positive health status changes and practice EM without or in addition to formal training. Many studies have investigated trained practitioners from various schools,14 suggest that feasibility studies are valuable when few published studies or data exist for a particular intervention and the sociocultural context of an intervention is unclear. Both of these considerations apply to patients and providers at community hospitals with respect to interventions involving solo EM practitioners. Bowen et al. believe that feasibility studies can lay the foundation for more rigorous research of therapeutic interventions by exploring their acceptability, demand, implementation, and integration, among other factors. Investigations for these dimensions of EM are needed to make future research in community hospital settings possible.Bowen et al.14 The study also documented conventionally recorded clinical changes immediately following EM.The present study investigated the feasibility of implementing EM with a single solo practitioner in the conventional inpatient, outpatient, and emergent settings of a community teaching hospital. Aspects of feasibility examined were acceptability, demand, implementation, and practicality, assessed in part through clinicians' qualitative responses.This feasibility study and prospective exploratory case series were conducted at Lutheran Medical Center, a full-service community teaching hospital located in Brooklyn, New York. The hospital's institutional review board (IRB) approved the study by expedited review in 4 days. The last author (K.J.) was the administrator of the IRB but was not a voting member or reviewer of the IRB. He was asked to meet with the medical director, the chair of the IRB, and the vice president for professional affairs to answer questions about EM, the practitioner, and the study before approval.15 no CAM or EM programs other than osteopathy and acupuncture existed at the time of the present study.A solo EM practitioner with 14 years of experience who had recently seen patients at the YinOva Center, a holistic wellness center in Manhattan, provided the EM sessions. The director of the YinOva Center (J.B.) founded the inpatient acupuncture program at Lutheran Medical Center in 2003 and was a trusted colleague. The decision to work with the EM practitioner and conduct the study was based on the director's experience with and knowledge of his work. While Lutheran Medical Center had osteopathic residency programs and an osteopathic medical school onsite, was oriented toward whole-person care , and was open to CAM,The EM practitioner was oriented to the medical center by the Volunteer Department, through which he was processed. The last author (K.J.) approached the physician unit leader and head nurse manager of three patient centers in the hospital to obtain permission to conduct the study on their units. Permission was granted for all three, after which this author conducted a brief in-service training for the unit's physicians, nurses, and allied health staff. The forms of energy medicine and the process of the study, including inclusion and exclusion criteria, were explained in a session lasting 15 to 30 minutes, depending on questions. The process of approaching the units and obtaining approval took about 2 weeks.9After the training, any health professional on the unit was eligible to identify a patient for potential inclusion, a process that took an additional week and required personal encouragement by the last author to initiate. The EM practitioner was supervised by attending physicians, residents, and nurses in study locations. Study physicians and the patient's attending physician approved each patient's participation and verified inclusion and exclusion criteria. Approved patients were approached by a member of the study team to obtain informed consent. Outpatients and nonpatients were evaluated and enrolled in a similar way.Using their clinical judgment, physicians identified as potential participants adult patients, employees, or friends or family of employees who had signs and symptoms that were not responding to traditional medical therapy or were only slowly responding. Patients deemed to have secondary gains for their medical condition or who were unable or unwilling to communicate with the research team regarding the effects of the energy medicine session were excluded from the study. Assessments by which improvement was typically gauged in this clinical setting were specified for each individual patient on the basis of the judgment of his or her treating physician.During each session, the solo EM practitioner was accompanied by a research team member and usually by other hospital staff already working with the patient, such as a nurse. Pretreatment assessments were made and recorded by a research team member with respect to the patient's expressed chief complaint. The EM practitioner was introduced to the patient and inquired about symptoms and goals for treatment, sitting at the bedside or in proximity to the patient. He sometimes positioned his hands over the affected area. No physical contact occurred between him and the patient. This generally lasted for a minute or two at a time, allowing the practitioner to receive ongoing feedback from the patient. He repeated the process several times as needed to address different problem areas, adjusting his method on the basis of information supplied by the patient. For some patients, the practitioner “energized” water that the patient then drank. This was done as follows. While with the patient, the practitioner placed his hands in proximity to a cup of water already in the patient's room and mentally directed energy to it without touch, in the same way as with the patient. The patient would then drink the water.At the session's conclusion, post-treatment assessments were recorded by the research team; these assessments of pain and other clinical indicators were carried out according to the hospital's standard of care. Some patients received additional sessions as reported in the tables, depending on improvement, availability, and the patient's wishes.Summary descriptive statistics were created for two subgroups of patients: those with complaints of pain and those requesting help with symptoms or signs not related to pain. Improvement of pain was rated as none (no change), slight , moderate , and marked (improvement of 6 points or more). Pain that resolved completely  was also classified as a marked improvement. Improvement of symptoms and signs other than pain was also rated on a scale of none, slight, moderate, and marked. The system by which standard assessments in our setting were converted into this rating scale was developed by consensus of all authors.Acceptability of EM was investigated by determining whether physicians would recommend patients for the study and whether patients would accept such treatment. Demand was investigated by recording the complaints for which patients and physicians requested EM sessions. Implementation was investigated by assessing whether the study's in-service and referral system resulted in a manageable number of sessions. Practicality was investigated by assessing the resources, time, staffing, and credentialing needed to carry out the study.The chi-square or Fisher exact test was used to determine significance of differences between assessments of change by subgroup of demographic and clinical characteristics.Thirty-two patients were treated with EM as part of the study. The 24 patients who requested relief from pain had a mean age of 55.5 years . Four (17%) were male and 20 (83%) were female. Eighteen (75%) were inpatients, and 6 (25%) were outpatients or employees . Of the p>0.05). The accompanying physicians noticed that when change took place during an EM session, that change was immediate.Twenty-one patients had a wide variety of issues other than pain . Their mRegarding acceptability and demand  and 2, pImplementation of EM was smooth. The study team found no significant change introduced by the EM sessions in their routine medical practice because it dovetailed with conventional goals of care and clinical assessments of progress. A few referring physicians commented that the speed of recovery was enhanced in patients who perceived positive clinical results; most did not inquire about the outcome. Regarding practicality, the study was practical in our setting because it was time limited, relied on assessments physicians typically make, and was staffed on a volunteer basis. The resources determined from carrying out the study that would be needed to implement EM as a formal program in the hospital were not available on the hospital's tight operating budget; thus, this EM program was not practical in our setting outside the study.Patient 31 was a 45-year-old woman with a diagnosis of metastatic breast cancer since 2003. Given the progression of her disease, pain became a major morbidity. On this admission, she presented with severe upper abdominal pain that had worsened in the previous 2 days. She reported that pain intensified with movement or touching of the affected area. During EM, she lay on her bed. In the room were two medical attendings and the EM practitioner. On initial assessment, the patient stated that her abdominal pain was improved to a score of 6 of 10 since admission but that she had significant (7 of 10) mid-lower back pain. The practitioner placed his hands approximately 10 inches above her right upper abdomen for approximately 20 seconds without touching her. Immediately afterward, she rated the abdominal pain to be 0 of 10. He addressed her lower back by placing his hands several inches over her umbilicus, after which she reported a pain score of 0 of 10. The practitioner asked her about the location of the cancer and did further work on the liver area. The patient was reassessed 15 minutes later and reported a sustained relief from pain in both areas.Patient 24 was a 72-year-old woman who presented to the emergency department with bilateral worsening knee pain, inability to walk, and inability to bend her knees. She had been told that she needed bilateral knee replacements, but her cardiac status contraindicated surgery. The patient arrived with her husband, who was sympathetic to her pain and frustrated by her inability to ambulate and the ineffectiveness of her pain medication. Before EM, her pain was 10 of 10 in both knees. She had less than 5 degrees of active range of motion. Passive range of motion was 3.5 degrees in the left knee and 0 degrees in the right knee. After the session, her pain was 0 of 10, and she had full active range of motion in both knees. She stood up and walked with a cane, smiling. Her husband applauded and said that he hadn't seen her do this in many years.This study found that integrating solo-practitioner energy medicine into inpatient and emergent hospital settings was largely feasible within the parameters of the study itself. In addition, it found significant immediate improvements in most patients after EM sessions with respect to symptoms of their medical conditions and, to a lesser extent, with signs. Before the sessions, physicians identified these signs and symptoms as in their judgment unlikely to change rapidly.16 and EM17–19 suggest a measurable benefit of EM with pain. Although the current clinical assessments of improvement are not directly comparable given the differences in study population and the EM modality used (solo practitioner), a clinically significant reduction of pain occurred in most of our patients. With respect to musculoskeletal and arthritic pain and limitation of movement, several studies20–23 suggest that function and range of motion can be improved along with pain. The current results concur with theirs.Published reviews of research on biofield healing2 However, the evidence for the effectiveness of biofield therapies in reducing fatigue and enhancing quality of life in these patients is still inconclusive.24 The current study included only five patients with cancer but suggests that EM can be of benefit in immediate relief of symptoms.Studies of the effectiveness of EM or biofield therapies on cancer-related symptoms  reported a trend toward improvement.25 For example, volunteer Reiki practitioners have been involved in the management of anxiety, pain, and global wellness in patients with cancer.26 Sessions were felt helpful in improving well-being, relaxation, pain relief, sleep quality, and reducing anxiety of patients attending an outpatient oncology and infusion services unit. This suggests that solo-practitioner EM in hospitals could benefit patients' physical and emotional needs.The present study provides information concerning how EM may feasibly be integrated into a hospital setting. Reiki programs in hospitals have often been staffed by volunteers and sometimes by professionals.13 Hospital staff had a wide range of opinions related to EM, but as evidenced by the volume of referrals to the EM practitioner, staff members who might not have otherwise recommended EM to patients did so. Given the popularity of CAM with patients, physicians might be persuaded to allow inpatient EM as being preferable to unknown CAM practices done outside of their supervision.Because the EM practitioner in our study was flexible regarding timing and location of sessions, it was logistically easy to provide sessions that did not interfere with traditional treatment. Further, the patients' treating physicians noted no evidence of adverse effects associated with EM at the time of final assessment after EM. The ethical principles of patient autonomy and non-maleficence, along with the lack of adverse effects and ease of integration of EM, encourage further use of this modality in the hospital setting.Issues related to clinical implementation encountered in designing and carrying out this study were as follows: (1) credentialing and status of the EM practitioner; (2) administrative approval, quality monitoring, and consent processes; (3) physician, nurse, and patient acceptance; and (4) payment. The following section briefly discusses each of these issues.First, because no form of EM with the exception of acupuncture is currently licensed, hospital credentialing may not be possible for other EM practitioners, even when associated with a specific school. Hospitals or clinics often offer Reiki with volunteers who have undergone the clinical institution's specific orientation, who are supervised by nurses and have the approval of physicians whose patients will receive Reiki. Since Therapeutic Touch and Healing Touch as forms of EM are generally considered to be within nurses' scope of practice, this is considered appropriate, and thus nurses may be able to supervise solo practitioners as well. As an official Lutheran Medical Center volunteer, the solo EM practitioner in the current study was covered by the hospital's general liability insurance; he made no physical contact with patients and so credentialing was not an issue. An extra layer of administrative approval would be needed if EM were provided outside of an IRB-approved research study, however.Second, even a volunteer EM program is not without cost, given the logistics of planning the program; enrolling, training, and supervising practitioners; and managing patient referrals. Thus, obtaining administrative approval is a critical and often thorny step for solo EM practitioners, more so than for those trained by specific schools. The EM program and its individual practitioners need to be monitored for quality, in both their adherence to program guidelines and clinical benefit, harm, and patient satisfaction (the tables in our study suggest ways of assessing benefit). Part of designing an EM program includes how consent will be handled. Each health system will need to decide whether a specific consent is obtained from the patient or whether the institution's overall consent is considered sufficient. State regulations play a role in this as well.Third, physician, nurse, and patient acceptance of EM sessions are equally important. Without physician and nurse acceptance, patients are unlikely to know about the service. In addition, patients' level of pain, religious beliefs, and worldview may block EM as an option they will consider. Approaching patients with sensitivity to these issues is important. Hospital chaplains may be able to assist with this process.Finally, a skilled EM practitioner may not be willing to offer services on a volunteer basis, although that was the case in the present study. Payment options will vary widely depending on the institution. A nurse could feasibly supervise an EM solo practitioner who receives compensation.27The limitations of this study mostly follow from the fact that EM research is complex and developing, with answers to key questions of mechanism, measurement, efficacy, and effectiveness still evolving. This limited the dimensions of feasibility that this study could investigate. Regarding the assessments of clinical benefit, the limitations are similar to those of any case series reporting on an innovative technique of treatment: unclear generalizability to a larger population with the same medical issues and difficulty in establishing reliable estimates of benefit. Furthermore, because the mechanism of EM is poorly understood, it is difficult to compare individual practitioners as to whether they will achieve similar results. Even with these limitations, the improvement patients experienced was often striking, providing justification for developing a clinical protocol whereby some solo EM practitioners could be integrated into clinical care after a period of assessment. It also suggests possibilities for how to document clinical assessments related to treatments given by solo EM practitioners and highlights the value of case series in exploring new techniques.28 Further, clinicians in the current study enrolled patients with refractory pain not responding to medication. They ruled out improvements that could have been caused by other treatments and had no reason to view EM in a way that would bias their judgment as to clinical changes associated with the EM session.Previous studies on Reiki and other forms of energy healing sometimes involved physical contact between the healer and patient. With the possible exception of a handshake, no physical contact between the EM practitioner and the patient occurred in this study. A 2013 study on therapeutic massage featuring touch and no-touch controls found a reduced placebo effect with the no-touch control, suggesting that the lack of contact in the present study strengthens the results and diminishes the placebo effect.The authors found the results of this feasibility study encouraging regarding the acceptability, demand, and implementation of energy medicine in an inner-city community hospital setting. The practicality of carrying out a study with a single volunteer practitioner was good, albeit different from implementing an ongoing program that needs to be supervised by hospital staff. The next step regarding feasibility could be a study that explores methods for finding and screening local EM solo practitioners (whether volunteer or paid) and for integrating them into conventional clinical settings.This study provides some guidance as to how EM can be applied clinically, especially in inpatient settings. It suggests that EM has a beneficial effect in some patients and provides some methodologic information that could be used in the design of stronger studies, such as funded feasibility studies of the integration of EM into conventional clinical settings.


Subjective symptoms of temporomandibular disorders (TMDs) have rarely been studied by age group. We aimed to compare self-reported pain intensity, sleeping difficulty, and treatment outcomes of patients with myofascial TMDs among three age groups.U test, the chi-square test, and analysis of variance (p < 0.05).The study population included 179 consecutive patients (151 women and 28 men) who underwent comprehensive clinical examinations at a university-based orofacial pain center. They were classified into myofascial pain subgroups based on the Research Diagnostic Criteria for Temporomandibular Disorders. They were stratified by age group: M1, under 20 years; M2, 20–39 years; and M3, 40 years and older. The patients scored their pretreatment symptoms (first visit) and post-treatment symptoms (last visit) on a form composed of three items that assessed pain intensity and one item that assessed sleeping difficulty. Their treatment options  and duration were recorded. All variables were compared between sexes in each group and between the age groups by using the Kruskal–Wallis test, the Mann–Whitney No significant sex differences were found in any age group. Only sleeping difficulty was significantly different before treatment (p = 0.009). No significant differences were observed in the treatment options or treatment duration. After treatment, the intensity of jaw/face pain and headache and sleeping difficulty was significantly reduced in groups M2 and M3, but only the intensity of jaw/face pain was significantly decreased in group M1. The changes in the scores of pain intensity and sleeping difficulty were not different between the groups.Pain intensity does not differ by age group, but older patients with myofascial TMDs had greater sleeping difficulties. However, there were no differences between the age groups in the treatment outcomes. Clinicians should carefully consider the age-related characteristics of patients with myofascial TMDs when developing appropriate management strategies. Temporomandibular disorders (TMDs) include musculoskeletal and neuromuscular conditions that involve the masticatory muscles, temporomandibular joint (TMJ), and associated structures . They arTMDs are associated with many diagnostic features such as internal derangements and myogenous disorders . They caSymptoms of joint-related TMDs resolve with minimal care . HoweverIn this study, we aimed to compare self-reported pain intensity, sleeping difficulty, and treatment outcomes of patients with myofascial TMDs among three age groups. We hypothesized that young patients are more likely to have mild symptoms and their symptoms are easy to treat, whereas older patients are more likely to show severe symptoms, which are difficult to treat.We screened 862 consecutive patients who attended the University of California–San Francisco (UCSF) Center for Orofacial Pain , a public university-based specialty clinic that treats TMD and orofacial pain problems. We used a prospective study approach to examine pretreatment and post-treatment differences in pain intensity and sleeping difficulty in the three age groups. We obtained the necessary data from the patients’ medical records. Ethical considerations were anonymity, privacy, and obtaining informed consent from all patients. The UCSF Committee on Human Research approved this prospective outcome study.The patients underwent standardized comprehensive clinical examinations by two examiners who were diplomates of the American Board of Orofacial Pain. The examinations included provocation testing of the TMJs, measurements of the mandibular and cervical ranges of motion, determination of TMJ noise, masticatory and cervical muscle examination, cranial nerve assessment, and intraoral examination. Additional diagnostic tests  were performed, if needed.The RDC/TMD guidelines were followed for classification, based on the primary diagnosis. Patients were excluded if they had neuropathic pain, generalized pain , neurovascular headache , or any psychiatric disorder. The RDC/TMD Axis I, Group I.a  or Group I.b  included a painful response to palpation of the following muscle sites: posterior temporalis, middle temporalis, anterior temporalis, origin of the masseter, body of the masseter, insertion of the masseter, posterior mandibular region, submandibular region, lateral pterygoid area, and tendon of the temporalis . PatientThe patients completed a form that assessed their symptoms at the first visit and at subsequent visits during the treatment period. In several studies, self-reported questionnaires focused on the intensity of TMD symptoms, headaches, and neck pain and related impact on activities of daily living –22. Selft test for age and treatment duration, and by the Mann–Whitney U test for pain intensity and sleeping difficulty. Analysis of variance (ANOVA) and the chi-square test were used for analyzing differences in treatment duration and sex ratio, respectively, between the age groups. The Kruskal–Wallis test was used to compare pain intensity and sleeping difficulty by age group. If a significant difference was found, a pair of variables in the three groups was assessed with the Mann–Whitney U test. Because three tests were performed, Bonferroni adjustment was applied with the alpha level set at p = 0.0167 . The Wilcoxon signed-rank test was used to compare subjective symptoms between the pretreatment and the post-treatment periods. A value of p < 0.05 was considered significant. All analyses were performed by using IBM SPSS Statistics 21 software .For each age group, sex differences were assessed with the Student No age group showed any significant sex differences. In general, 84.4% 151/179) of the study population included female patients with a higher proportion in group M3 (88.2%) than in groups M1 (80.5%) or M2 (82.3%). However, the sex ratio was not significantly different between the age groups  , but scored significantly higher than group M1 .Pretreatment pain intensity was not significantly different among the age groups Table . HoweverRegarding treatment options, patients in groups M2 and M3 were more likely to receive pharmacotherapy, compared to patients in group M1  and elderly patients (50–70 years) with TMDs  showed tApproximately one-third of patients with TMDs report poor sleep quality . NumerouWe did not assess treatment effectiveness. Because of this limitation, we cannot describe the most effective treatment for symptoms of myofascial TMDs in young or elderly patients. However, tailored treatment protocols are necessary for patients with TMDs. Further well-designed studies are needed to clarify the effects of each treatment and the effects of patient compliance with a home-care program on reducing orofacial pain and difficulty in sleeping.Pain intensity associated with myofascial TMDs does not differ by age, but older patients experience greater sleeping difficulty, compared to young patients. Conservative treatment strategies can reduce pain in the jaw or face region at all ages. Treatment outcomes of self-reported pain intensity and sleeping difficulty are not different between different age groups. Clinicians should carefully consider the age-related characteristics of patients with myofascial TMDs when developing appropriate management strategies.


The aim of the present study was to compare the effect of two different rotary instruments on postoperative pain in teeth with asymptomatic irreversible pulpitis. n=39) and their root canal preparation was carried out with either RaCe or ProTaper rotary instruments. All the subjects underwent one-visit root canal treatment and the severity of postoperative pain was evaluated using visual analog scale (VAS) at 4-, 12-, 24-, 48- and 72-h and 1-week intervals. In addition, the need for taking analgesics was recorded. Data were analyzed with the repeated-measures ANOVA and the Mann-Whitney U test was used for two-by-two comparison. Statistical significance was set at 0.05. A total of 78 mandibular first and second molars were divided into two groups (P=0.10). The difference in amount of analgesics taken by each groups was not statistically significant (P=0.25).  Comparison of mean pain severity between the two groups at various postoperative intervals did not reveal any significant differences (There were no significant differences in the postoperative pain reported between the two groups; which indicates the clinical acceptability of both systems. Incidence of endodontic postoperative pain subsequent to endodontic treatment ranges from 1.4 to 16% . EvidencSeveral factors affect the extrusion of debris, including the irrigation protocol , the finThe majority of recently introduced nickel-titanium (NiTi) rotary instruments result in minimal debris extrusion compared to the stainless-steel hand K-files, which is attributed to their rotary action, Archimedes’ screw effect and copious irrigation associated with these instruments . Two of RaCe instruments consist of two grooves followed by one straight grooves-free area along the file, for accumulation and evacuation of debris, which results in a decrease in screw-in effect, along with enlargement of the coronal area of the root canal. This design also provides a passageway for debris to escape from the root canal that reduces the apical extrusion of debris, resulting in less severity of postoperative pain .ProTaper instruments possess a convex triangular cross-sectional design and flutes along the file that are combined with variable tapers along the file shaft. It has been claimed that such a design is more effective in cutting dentin .et al. [ demonstrated no statistically significant difference in the postoperative pain among the patients whose teeth were treated with ProTaper or K-Flexo hand files at any time period. Based on a study by Nekoofar et al. [Ahmed et al.  reportedet al. [ demonstrr et al.  the postet al. [et al. [et al. [Tasdemir et al.  showed t [et al.  reported [et al.  showed tSince there is no clinical trial available to compare postoperative pain after the endodontic treatment using RaCe and ProTaper rotary instruments, the present study was undertaken to compare the severity of postoperative pain after endodontic treatment of the first and second mandibular molars with asymptomatic irreversible pulpitis using these two common systems.This study was approved by the Ethics Committee of Tabriz University of Medical Sciences (Grant No.: 1394.47) and was registered at Iranian Registry of Clinical Trials (Registration ID: IRCT201503035141N3).α=0.05 and power of 80%, the sample size was estimated to be 78 (n=39). All the subjects were treated in the Postgraduate Clinic of the Department of Endodontics, Faculty of Dentistry, Tabriz University of Medical Sciences, Tabriz, Iran.After conducting a pilot study and considering All patients had a first or second asymptomatic mandibular molar diagnosed with irreversible pulpitis and a normal periapical radiographic view. Before initiation of treatment, the whole procedural steps were explained to the patients. Then the patients signed an informed consent form. The inclusion and exclusion criteria are shown in Patients were randomly treated by choosing a packet in which the type of the instrument was written. The patients were unaware of the types of the instruments used for endodontic treatment; therefore, the study was considered a single-blind one. All the subjects underwent standard IANB anesthesia and long buccal infiltration with 2% lidocaine containing 1:80000 epinephrine  with a side-loading cartridge syringe  and 27-G long needles . After aspiration at the target area, the solution was injected at a rate of 1 mL/min. After 15 min, the subjects were questioned about the presence of lip numbness and the teeth were re-examined with similar cold pulp sensitivity test and electric pulp test to confirm pulpal anesthesia. In some cases supplementary injections were used, followed by isolation of teeth with a rubber dam and endodontic access cavity preparation. Then the root canal orifices were located. n=39).All the procedures were performed by one clinician in order to eliminate or minimize interpersonal variability in the treatment procedures. The initial working length was recorded with a #15 K-file  and an apex locator  and confirmed by digital radiography. In both groups the working length was 0.5-1 mm shorter than the length determined using the radiographic technique . The patIn the RaCe group, RaCe instruments  were used in crown-down technique according to the manufacturer’s instructions; with the following sequence: 40/0.10 and 35/0.08 for the preparation of the coronal third of each root canal followed by 30/0.06 in the middle third, #25/0.04 in the apical third and #30/0.04 up to the working length. The final apical size was achieved with #30/0.04 or #35/0.04 file. All preparation procedure was done using gentle in-and-out motions and the instruments were pulled out when resistance was encountered and the next instrument in the sequences was used. In the other group, ProTaper  instruments were used in the crown-down technique according to the manufacturer’s instructions, with motions similar to those with RaCe instruments. The instrumentation sequence was as follows: SX  was used to shape the coronal portion of the root canal, followed by S1 (tip size 20) in the coronal third and S2 (tip size 19) in the middle third; in addition, both instruments were used to progressively enlarge the apical third. Finally, the finishing files  were used to finish the apical third. The final apical preparation diameter was matched to K-file #30 or #35, depending on the initial apical size and the canal curvature. Concomitant with the use of rotary files for cleaning and shaping of the root canals, gel-form 17% EDTA  was used as a lubricant. During all the preparation procedures with both rotary systems, the root canals were irrigated with 30 mL of normal saline using a syringe connected to a 25-guage needle after each file. The needle was inserted into each root canal as far as possible, without binding. Finally the pulp chamber and the root canals were irrigated with 5 mL of 2.5% sodium hypochlorite solution. After the final rinse with normal saline solution, the root canals were dried with paper points and the standard ISO-sized matching master cones were fitted and checked with radiography. Then the root canals were obturated with gutta-percha  and AH-26 sealer , using the lateral compaction technique. A temporary filling material  was placed and the occlusion was checked. Then the patient was referred to the restorative department for the final restoration.The patients were calibrated and asked to mark their pain on a visual analogue scale (VAS) at 4-, 12-, 24-, 48- and 72-h and 1-week postoperative intervals. Although no systemic medications were prescribed, the patients were instructed to take mild analgesics  in case of pain perception and record it. Since ibuprofen has dose-dependent activity and its analgesic effect completely disappears after 8 h , these pThe VAS was divided into the following 6 categories during data analysis: 0 mm; no pain, 0-20 mm; mild pain, 20-40 mm; moderate pain, 40-60 mm; severe pain, 60-80 mm; very severe pain and 80-100 mm; the worst pain conceivable [The SPSS statistical package  was used for statistical analysis. The data were then analyzed with repeated-measures ANOVA; the Mann-Whitney U test was used for two-by-two comparisons. Statistical significance was set at 0.05.P<0.001)   Table 2P<0.001 (P=0.10). Comparison of mean pain severity between the two groups at various postoperative intervals did not reveal any significant differences between the two groups (P>0.05). At 12-, 24-, 48- and 72-h and 1-week postoperative intervals, the pain severity in the ProTaper group was less than that of the RaCe group; after 48- and 72-h the difference was significant (P<0.001), however, after 12-, 24-h and 1-week intervals, the differences in pain severity between the two groups were not significant (P>0.05)   Table 2P>0.05. ADuring the first 24 h, 17% of patients from both groups had no pain and 5% in RaCe group and 2% in ProTaper group had the worst pain conceivable.P=0.25).The number of patients taking analgesics during the first 24-h postoperative period was 20 (51.3%) and 15 (38.5%) in RaCe and ProTaper groups, respectively, with no significant differences between the two groups  which reduces the apical extrusion of debris , and thiInvestigators suggested that presence of preoperative pain and presence and size of periapical radiolucency are related ; in thisBased on a study by Seltzer , there iIn the present study, all the subjects underwent one-visit root canal treatment because a meta-analysis showed that patients undergoing one-visit root canal therapy exhibited significantly less endodontic postoperative pain compared with those undergoing a two-visit treatment protocol . et al. [Cold lateral condensation obturation technique was used in the present study because Alonso-Ezpeleta et al.  reportedMedicines from the NSAID family are usually administered as the first analgesic choice subsequent to root canal treatment, among which ibuprofen is the most commonly used medication . It was Pain is usually manifested a few hours or days after root canal treatment, necessitating unscheduled visits ; therefoPostoperative pain steadily decreased over time. After a day, the mean pain severity exhibited a decrease of 40%. Seven days after treatment, the pain severity decreased to less than 10% [et al. [et al. [et al. [Tasdemir et al.  showed t [et al.  reported [et al.  showed tin vitro results to clinical situations. In addition, there were no significant differences between the two groups regarding the use of analgesics during the first 24-h postoperative interval.One of the reasons for the absence of significant differences in postoperative pain between the two rotary groups in the present study might be the fact that periapical tissues serve as a natural barrier against extrusion of debris, preventing extension of the Future research is suggested to compare postoperative pain experienced by patients with symptomatic irreversible pulpitis and pulp necrosis after root canal preparation with RaCe and ProTaper rotary instruments.This study showed no significant differences in the postoperative pain experienced by patients between the two rotary groups, indicating the clinical acceptability of both endodontic techniques.


A headache circumscribed in a line-shaped area but not confined to the territory of one particular nerve had ever been described in Epicrania Fugax (EF) of which the head pain is moving and ultrashort. In a 25-month period from Feb 2012 to Mar 2014, we encountered 12 patients with a paroxysmal motionless head pain restricted in a linear trajectory. The head pain trajectory was similar to that of EF, but its all other features obviously different from those of EF. We named this distinctive but undescribed type of headache linear headache (LH).A detailed clinical feature of the headache was obtained in all cases to differentiate with EF, trigeminal autonomic cephalalgias (TACs) and cranial neuralgia. Similarities and differences in clinical features were compared between LH and migraine.The twelve LH patients (mean age 43.9 ± 12.2) complained of a recurrent, moderate to severe, distending (n = 9), pressure-like (n = 3) or pulsating (n = 3) pain within a strictly unilateral line-shaped area. The painful line is distributed from occipital or occipitocervical region to the ipsilateral eye (n = 5), forehead (n = 6) or parietal region (n = 1). The pain line has a trajecory similar to that of EF but no characteristics of moving. The headache duration would be ranged from five minutes to three days, but usually from half day to one day in most cases (n = 8). Six patients had the accompaniment of nausea with or without vomiting, and two patients had the accompaniment of ipsilateral dizziness. The attacks could be either spontaneous (n = 10) or triggered by noise, depression and resting after physical activity (n = 1), or by stress and staying up late (n = 1). The frequency of attacks was variable. The patients had well response to flunarizine, sodium valproate and amitriptyline but not to carbamazepine or oxcarbazepine. LH is different from EF, trigeminal autonomic cephalalgias (TACs) and cranial neuralgia, but it had couple of features similar to that of migraine.The clinical picture of LH might be a subtype of migraine, or represent a novel syndrome. Head pain of intracranial or extracranial, such as cranial neuralgia, nummular headache, migraine and cluster headache, may be confined within a restricted area. But a headache area shaped in a linear trajectory which is not confined to the territory of one particular nerve has never been reported before the first report of Epicrania fugax (EF) by Pareja et al. in 2008 . EF is cIn a 25-month period (Feb 2012 to Mar 2014), we encountered twelve patients with stereotypical headaches. All the patients complained of a paroxysmal headache in an area of linear trajectory from occipital or occipitocervical region to the ipsilateral nose, forehead or parietal region. A detailed history was obtained in all cases and a special attention was paid to medical history of head trauma or macroscopic changes of the scalp. Patients were asked to point out the exact location of the pain-affecting area and to delineate it in size and shape. A complete history of duration, intensity, and quality of the headache at baseline and during exacerbations, presence of nausea, vomiting, phonophobia and photophobia was recorded. A complete physical and neurological examination was performed in all cases. Inspection, palpation and sensory examination of the affecting area, as well as palpation of the supraorbital, infraorbital, minor occipital and greater occipital nerves were included in the examination. Routine blood work-up with erythrocyte sedimentation rate, computed tomography (CT) or magnetic resonance imaging (MRI) of the head and electroencephalogram (EEG) were performed in all cases to exclude any underlying disease. Diagnosis of other concomitant headache syndromes was based on the 2nd Edition of The International Headache Classification (ICHD-II) criteria .Among the twelve reported patients Table , six wasThe clinical features are shown in Table With regard to examination, no skin change was noted along the painful linear trajectory either during the ictal period or during the interictal period in all patients, but a hyperaesthesia to light touch noted along the painful linear trajectory in three patients . Regional mild pain was noted in two patients while palpating the supraorbital or greater occipital nerves, but no abnormal sensation noted in all other patients. Neurological examination, MRI, EEG and blood tests were normal in all patients.Ten of the twelve patients accepted medical treatment and had good responses. Two patients (patient 1 and 2) treated with flunarizine (5 mg twice a day) alone had the headache recurrence prevented, but got the headache recurred days after stopping taking flunarizine. Two patients treated with amitriptyline (25 mg twice a day) alone (patient 3 and 6) and one patient treated with flunarizine (5 mg twice a day) alone (patient 8) had the frequency and intensity of the headache reduced. Two patients treated with sodium valproate (500 mg twice a day) alone (patient 5) or together with flunarizine (5 mg twice a day) (patient 7) had the headache recurrence prevented. Carbamazepine (200 mg three times a day) usage failed to relieve the linear headache in three patients  who had short duration of linear headache. Among these three patients, patient 7 and 8 then accepted treatment with flunarizine (5 mg twice a day) alone and had the headache severity and frequency reduced, further, patient 7 accepted treatment with flunarizine (5 mg twice a day) in combined with sodium valproate (500 mg twice a day) and had the headache recurrence prevented.Here we report twelve patients presenting with a previously undescribed headache with consistent features both intra-individually and inter-individually. The main feature of this headache is a paroxysmal head pain restricted in a linear trajectory linking the occipital or occipitocervical region and the ipsilateral nose or forehead region. This line-shaped trajectory is similar to that described in EF. Apart from the similar pain area, a linear trajectory, all other features are obviously different from those of EF but apparently similar to those of migraine. The clinical features of this new condition apparently constitute a new headache entity, and we have named it LH.As LH pain is circumscribed in an area of linear shape and this line-shaped trajectory is similar to that of EF pain -7, we neRecently, Serna-Candel et al. described three cluster headache (CH) patients whose typical CH attacks started with mild or moderate pain of dull or tightening character at the occipital region and gradually moved forward over 10 to 30 minutes, finally reached the ipsilateral orbital area, and the authors named this headache “ascending CH” . The LH The pathogenesis of LH is unknown. It is common for headache patients including migraineurs to localise their pain to a particular area of occipital, parietal, frontal, and orbital region . RecentlLH presents an undescribed, clear-cut clinical picture that may be distinguished from other headaches. It is basically characterized by recurrent unilateral pain circumscribed in a line-shaped area from the occipital or occipitocervical region to the ipsilateral nose or forehead region, accompanied with or without nausea, vomitting and dizziness. LH might be a subtype of migraine, but might also represent a novel syndrome. At this stage, no definite explanation can be provided, but the clinical features point to a pathophysiological pathway similar to that of migraine. Further observations are required for a definitive characterization of these headaches, and the study of the LH pathophysiology may help to elucidate the mechanisms of migraine.EF: Epicranial fugax; LH: Linear headache; CHD: International classification of headache disorders; MRI: Magnetic resonance imaging; CT: Computed tomography; EEG: Electroencephalogram; SON: Supraorbital nerve; GON: Greater occipital nerve; TN: Trigeminal neuralgia; ON: Occipital neuralgia; TACs: Trigeminal autonomic cephalalgias; SUNCT: Short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing; SUNA: Short-lasting unilateral neuralgiform headache attacks with cranial autonomic symptoms; CH: Cluster headache; RPON: Recurrent painful ophthalmoplegic neuropathy; OM: Ophthalmoplegic migraine; CSD: Cortical spreading depression; SSS: Superior sagital sinus.The authors declare that they have no competing interests.YW interviewed, diagnosed and treated the patients, interpreted the data and drafted the manuscript for content. All other authors listed contributed to the follow-up of the patients and literature reviewing. All authors read and approved the final manuscript.


The choroid plexus, located in brain ventricles, has received surprisingly little attention in clinical neuroscience. In morphometric brain analysis, we serendipitously found a 21% increase in choroid plexus volume in 12 patients suffering from complex regional pain syndrome (CRPS) compared with age- and gender-matched healthy subjects. No enlargement was observed in a group of 8 patients suffering from chronic pain of other etiologies. Our findings suggest involvement of the choroid plexus in the pathogenesis of CRPS. Since the choroid plexus can mediate interaction between peripheral and brain inflammation, our findings pinpoint the choroid plexus as an important target for future research of central pain mechanisms. The choroid plexus is the key producer of cerebrospinal fluid, which provides a fluid cushion for the central nervous system and a sink for nervous-system biomarkers and debris13Until now, the choroid plexus has been largely neglected in clinical neuroscience and its potential role in neurological disorders has remained unresolved678Here, we report an unexpected association between choroid plexus volume and central pain. Using MRI, we found choroid plexus enlargement in patients suffering from complex regional pain syndrome (CRPS), a chronic and multifactorial pain disorder that initially follows a minor peripheral trauma and subsequently spreads to areas beyond the original lesion area112 = 0.36, FDR-adjusted p = 0.041). The right lateral-ventricle choroid plexus was 21.1% larger in the CRPS patients compared with the healthy control subjects , and 12.6% larger than in the other control group consisting of patients suffering from chronic pain of other etiologies . We also found a large group effect on the volumes of the left lateral ventricle  = 6.84, η2 = 0.32, uncorrected p = 0.0037, FDR-adjusted p = 0.054) and the right thalamus  = 5.46, η2 = 0.27, uncorrected p = 0.0097, FDR-adjusted p = 0.094). Patients with CRPS had a larger left lateral ventricle  and smaller right thalamus  than the healthy control subjects. No statistically significant group effects were observed for any of the other structures examined , a hydrophobic water-transporting protein expressed at the plasma membrane of choroid plexus epithelial cellsIn summary, our results demonstrate an earlier-unexplored association between the choroid plexus and central pain. As limitations of our study we acknowledge the small sample size that resulted in limited statistical power, with the risk for type I errors despite the large effect size. Moreover, while all of our subjects suffered from right-sided pain, our data do not explain the right-hemisphere lateralization of the effect. However, our findings suggest that quantifying choroid plexus volume by contrast-enhanced MRI in future studies with larger cohorts could improve our understanding of the pathophysiology underlying CRPS. Finally, pairing these studies with animal models of CRPS could open avenues for developing improved diagnostics and therapeutic approaches for CRPS.This study was approved by the ethics committee of the Helsinki and Uusimaa Hospital District. Subjects signed informed consent before participation, and all methods were carried out in accordance with the approved guidelines.We analyzed the structural MRIs of 32 right-handed subjects: (1) twelve CRPS type 1 patients , (2) eight chronic pain patients of other etiologies , and (3) twelve healthy control subjects .During subject recruitment, CRPS diagnosis was confirmed by clinical examination performed by an experienced neurologist at the Pain Clinic of the Helsinki University Hospital. Eleven patients fulfilled the “research criteria” for CRPS, and the remaining patient fulfilled the less stringent “clinical criteria” for CRPSPrior to MRI measurements on the test day, CRPS patients reported a pre-MRI mean pain intensity of 5.5 ± 1.6 (range 3–7) on scale from 0 (no pain) to 10 (maximum pain), and the patients of the control group reported a mean pain intensity of 5.8 ± 1.8 (range 3–8). Neither disease duration nor pain intensity were found to differ between the two patient groups .3 T1-weighted MR images at the Advanced Magnetic Imaging Centre of Aalto NeuroImaging, Aalto University. Nine CRPS patients, eight control pain patients, and nine healthy control subjects were scanned with a Signa 3T scanner  with a 16-channel head coil. Four CRPS patients and four control subjects were scanned with a Magnetom Skyra 3T scanner  with a 30-channel head coil.We acquired high-resolution 1 × 1 × 1 mmImages were acquired with ultrafast gradient-echo 3D sequences  with 176 sagittal slices and a matrix size of 256 × 256. For the CRPS patients and healthy control subjects, the other imaging parameters were TR 10 ms/2530 ms, TE 2.9 ms/3.3 ms, flip angle 15°/7° for GE/Siemens scanner. For the control pain patients (GE scanner) the corresponding parameters were TR 9 ms, TE 1.9 ms, FA 15°.http://surfer.nmr.mgh.harvard.edu). The processing included motion correction, removal of non-brain tissue using a hybrid watershed/surface deformation procedure27Volumetric segmentation of the MRI images was performed in a standard manner using Freesurfer image analysis suite  controlling procedureWe calculated the Pearson correlation  between disease duration and all brain volumes where our previous analysis had indicated a statistically significant group effect in the CRPS cohort.How to cite this article: Zhou, G. et al. Enlargement of choroid plexus in complex regional pain syndrome. Sci. Rep. 5, 14329; doi: 10.1038/srep14329 (2015).


To determine which of three methods of pain management provided the best pain control in severe ASA III older patients in the surgical ICU (SICU). As technology improves, more older patients benefit from surgery and need SICU care. Older surgery patients frequently present two medical problems. First is unspecific symptoms and decreased pain sensation resulting in delayed diagnosis. Second, they usually are not given enough perioperative pain relief. Optimal pain management results in perioperative stable hemodynamic status and decreased morbidity, mortality, length of stay and medical costs.A retrospective cohort study chart review of 1,872 all-cause patients in a 16-bed SICU during April 2011 to September 2012. Unconsciousness, uncooperative, ASA <III and <65-year-old patients were excluded. The primary point was to compare effectiveness of three different methods of pain management: P.R.N. i.v. Demerol/NSAID (D/N), i.v. patient-controlled analgesia (PCA) and patient-controlled epidural analgesia (PCEA), in three different conditions: rest, movement and coughing, with visual analogue scales (VAS 0 to 100). Secondary point was patient satisfaction.A total of 1,292 patients were excluded. VAS results are presented in Table PCEA provided better pain control at rest than the other two methods, whereas P.R.N. Demerol/NSAID and PCEA were somewhat better than PCA when patients were moving. While coughing, P.R.N. Demerol/NSAID provided the best pain control. However, patient satisfaction was significantly better with PCEA.