The coronavirus disease 2019 (COVID-19) has emerged as a worldwide pandemic since March 2020. Although most patients complain of moderate or severe pain, these symptoms are generally underestimated and appropriate treatment is not applied. This study aims to guide physicians in selecting and ranking various alternatives for the treatment of pain in COVID-19 patients. However, the choice of treatment for pain requires the consideration of many different conflicting criteria. Therefore, we have studied this problem as a multicriteria decision-making problem. Throughout the solution procedure, first, the criteria and subcriteria affecting the preferences are defined. Then, weight values are determined with respect to these criteria, as they have different degrees of importance for the problem. At this stage, hesitant fuzzy linguistic term sets (HFLTSs) are used, and thus, experts can convey their ideas more accurately. In this first phase of the study, an HFLTS integrated Analytic Hierarchy Process (AHP) method is utilized. Subsequently, possible treatment alternatives are evaluated by using the Vise Kriterijumska Optimizacija I Kompromisno Resenje (VIKOR) method. According to the results obtained by considering expert evaluations, the most preferred treatment is the administration of paracetamol, followed by interventional treatments, opioids, and nonsteroidal anti-inflammatory drugs (NSAIDs), respectively. With this study, it is ensured that a more accurate method is followed by eliminating possible mistakes due to the subjective evaluations of experts in the process of determining pain treatment. This method can also be used in different patient and disease groups. The coronavirus disease 2019 (COVID-19), a highly contagious virus disease, was first found in China in December 2019. The World Health Organization (WHO) declared COVID-19 as a pandemic in March 2020. To date, more than forty million patients and approximately twelve hundred thousand deaths have been reported worldwide .Step 3: transform the preference relations into HFLTS by using the transformation function PC− and PC+). Compute the pessimistic and optimistic collective preference for each alternative using 2-tuple sets. The 2-tuple set associated with S is defined as S=Sx⟶S is given asStep 4: obtain the pessimistic and optimistic collective preference relations  of collective preferences for the alternatives piR=.Step 5: build a vector of intervals Step 6: calculate the midpoints of the intervals and normalize the results in order to find the weights.The main steps of the algorithm are defined as follows :Step 1: After the criterion weights are determined, the alternatives are evaluated based on these criteria. For this purpose, VIKOR method is used in this study. The VIKOR method, which was first referred to by Opricovic , was usefi∗) and worst (fi−) values are determined for each of the evaluation criteria. If criterion i  is defined in terms of “benefit” for evaluation, fi∗ and fi− can be expressed as follows:Step 1: the best  indicates the weight of the minimum regret of the opponents [v=0.5 is used [In equation , S∗=minjpponents . Usually is used .Qj, Sj,  and Rj are listed. The evaluation unit with the smallest Qj value is expressed as the best option in the alternative group.Step 4: calculated values of Q value be considered the best or the most suitable.Step 5: two conditions must be met in order for the obtained result to be considered valid. Only in this way can an alternative with the minimum The steps of the method can be summarized as follows:It states that there is a distinct difference between the best and the closest to the best options:P1 is the first best alternative with the lowest Q value and P2 is the second best alternative. It is expressed as follows: (Q)=1/(j − 1). j indicates the number of evaluation units. If the number of evaluation units is less than 4, then D(Q)=0.25 [In this equation, (Q)=0.25 .P1 with the best Q value should have achieved the best score in at least one of the S and R values.Alternative P1 and P2, alternatives If P1, P2,…, PM alternatives which are expressed by considering the inequality of Q(PM) − Q(P1) ≥ D(Q) If If one of the two specified conditions cannot be met, the compromised solution set is recommended consisting ofS was defined:The method described in the previous section was applied to the problem of pain treatment ranking and selection in mild to moderate COVID-19 patients. As mentioned before and presented in At this stage of the study, the calculations performed on the basis of the main criteria were given so that the reader would have a better insight over the method steps. First, pairwise evaluations were asked from the experts presenting their linguistic comparisons related to the main criteria. These evaluations are given in At the last step, after converting the linguistic intervals into interval utilities, the midpoints of these utilizes were calculated and normalized in order to obtain the weights. Related interval values and midpoints, together with the weights obtained for the main criteria, are given in Applying the same procedure for both the main and subcriteria, the resulting weights given in fij represents the value of ith criterion for the jth alternative and is a binary value. Values of fij's here are determined according to the convenience of the alternative for the existence of that specific criterion. For example, under the subcriterion C11, alternatives Alt. 1, Alt. 2, and Alt. 3 are preferred for whole body pain, whereas alternative Alt. 4 is not appropriate for this indication. All other values were assigned accordingly. Once the alternatives are scored, related best (fi∗) and worst (fi−) values are determined for each criterion. At this point, while defining fi∗ and fi−, 1 and 0 values were assigned for the best and worst values, respectively, with the aim of choosing the most effective treatment alternative with respect to each criterion. The values obtained as a result of this scoring are given in After defining the criteria and subcriteria, quantitative assessment values were assigned for possible situations, and alternative treatments were scored. As it is previously defined, Sj and Rj values were calculated taking the previously calculated weight (wi) values into account. At the next step, S∗, S−, R∗, and R− were defined, and Qj was obtained using equation , Alt. 3 (opioids), and Alt. 2 (NSAIDs) seem to be the second, third, and fourth treatment methods, respectively. However, they do not have a comparative advantage over each other, so we conclude that they all are the second ranked alternative treatments for these patients having slight changes of “costs” and “benefits.”Alternative 1, namely, paracetamol, is the best ranked treatment method based on the COVID-19 patients frequently have pain complaints in different forms. However, in these patients, pain-relieving treatments are often ignored and even avoided due to the current uncertainties about the disease and the published confusing reports. Despite the high prevalence of pain in these patients, there is no concrete guide on pain management, and the choice of treatment is based on personal decisions and preferences. In such cases, there are many independent and often contradictory criteria, and all these criteria should be considered for making the decision. In this study, considering the complex structure of the problem of determining the appropriate treatment method for COVID-19 patients with pain complaints, we attempted to use a scientific approach.In this study, the evaluations of specialists and the related literature were considered. In particular, the evaluations made by the experts were of great importance in determining the criteria and their relative weights while comparing alternatives. Regarding this situation, HFLTS definitions were utilized by predicting the hesitations of experts in the decision-making role. Thus, decision-makers were able to make subjective evaluations more easily, and the validity and reliability of their assessments improved. Furthermore, by rigorously reviewing the MCDM literature, it was found that the AHP + VIKOR approach is the most suitable method for this specific decision problem. Consequently, the method that we have applied is determined to be an HFLTS integrated AHP + VIKOR procedure. As a result of our analysis, the most preferable treatment was determined to be paracetamol, followed by interventional treatments, opioids, and finally NSAIDs.Paracetamol is a drug that has both antipyretic and analgesic effects. It is also safe in terms of side effects. It has no contraindications, except for severe liver failure. It can also be synergistically combined with other analgesic drugs. As a result, paracetamol is determined to be the first choice in the treatment of pain in COVID-19 patients. Interventional pain treatments are in second place. Some of the reasons include the procedure being targeted to the painful area instead of the whole body, lack of systemic side effects, and low risks of follow-up and complications. Despite the risk of respiratory depression in the acute period and addiction in the long term, the third ranked method of treatment is opioids. Its main advantages are use in severe pain levels and positive effects on coexisting symptoms such as cough and diarrhea. Additionally, it can be used in patients with kidney dysfunction and stomach problems. The most important reason for NSAIDs to be least preferred is the occurrence of systemic side effects and the risks of gastric and nephrological complications. In addition, negative reports about NSAIDs have also negatively affected the preference of physicians for these drugs.The main contribution of this study is to provide a guideline regarding pain management in COVID-19 patients and to determine the most appropriate treatment modality for these cases. The HFLTS integrated AHP + VIKOR procedure is proposed for this purpose. Accordingly, it is predicted that paracetamol should be used first in these patients, and then interventional methods, opioids, and NSAIDs are preferred. As previously mentioned, this is the first such study and the results obtained here are expected to guide physicians in treatment planning. This approach can also be used to address other decision-making problems in healthcare management.The most evident advantage of the proposed method is the use of HFLTS definitions. Through these definitions, decision-makers can make subjective evaluations more easily, and the validity and reliability of their assessments are improved. Second, the problem of determining the appropriate treatment method for COVID-19 patients with pain complaints has a complex structure and necessitates the use of a scientific approach. This study presents this scientific approach in the context of the relevant MCDM literature.This study has specific limitations, such as the number of experts consulted. Increasing this number can possibly reduce bias related to the subjective evaluations of decision-makers. The second limitation is the exclusion of the age factor, which affects both the progress of the disease and the metabolism of the drugs in patients. In addition, newly proposed methods may be used in future studies. Some examples include recent extensions on HFLTSs, such as probabilistic hesitant fuzzy sets –43 and d


The first half of 2020 has seen a significant change in the way we work, live and play and, for many, has forced us to evaluate the most important things in life. Our priorities and goals for the future may have changed, and the way we perceive our work/life balance may well have altered substantially. Likewise, the National Health Service (NHS), regardless of whether in a devolved nation or not, has seen a fundamental shift in its capacity and capability and an increase in the demand on its resources in a manner unprecedented and at a scale never seen before, altering the way both clinicians and patients view the NHS. Pandemic viruses know no boundaries and do not respect devolution or national pride, and we have seen the different approaches taken across the United Kingdom and the effect this has had on the NHS. However, regardless of location it is notable that pain services, covering both acute and chronic pain populations have all suffered the same fate. Doctors re-assigned to concentrate on other clinical areas, and physiotherapists, occupational therapists, psychologists, nurses and pharmacists, and a multitude of others, all moved to support intensive care and high dependency areas, wards and the community in order to play their part in the pandemic response.The significant reduction in resources to pain service provision did not see the disappearance of the need for such services, and it is a concern for many clinicians as to the impact the pandemic response will have on patients now and in the future. Indeed, it was a testament to the professionalism and caring nature of staff remaining in such clinics who developed innovative ways to provide some degree of support to patients. Digital technology featured highly as a new approach, with telephone and video consultations utilised for triage, assessment, and reviews; roll-out and updates of IT hardware and software across the United Kingdom; and the speedy creation and compilation of online resources to be offered to patients. However, little is known of the efficacy or sustainability of such approaches or of the impact it will have on patients unable, or unwilling, to access such technology.1 However, it is unlikely that these will be uniform across regions, and ongoing social distancing will have a direct effect on the capacity clinics have available to them to see patients and, indeed, accommodate their staff. The expectation that clinics will take the opportunity to review their approaches will no doubt be a significant factor in ongoing commissioning and service reviews and it is clear that the current use of digital technologies will be here to stay, despite their initial emergency instatement.2As lockdown eases across the United Kingdom, pain services will gradually increase their resources and ability to assess and treat patients.British Journal of Pain contains a number of interesting articles relevant to the clinical treatment of pain. As pain services slowly rise out of the ashes into a new, post-COVD-19 NHS, taking on a new persona reflective of new circumstances, those articles exploring the predictors of first-appointment attendance at a pain service, smartphone technologies, and digital pain programmes are likely to hold particular relevance. Going forward, it will be important that any new initiatives, and innovative technology, utilised to assist in treating patients digitally or otherwise remotely are evaluated carefully addressing both quantitative outcomes related to easing of pain and the qualitative experience of patients. Journals such as this, with a focus on pain, will take on an important role in the timely dissemination of conclusions from these studies to allow clinicians to quickly apply and adapt such findings to their daily clinics.This issue of the 3 to treatments simply to meet demand in areas with reduced capacity and a markedly increased waiting list. Indeed, to do so would likely increase difficulties faced by both patients and clinicians as approaches applied inappropriately would lead to an increase in chronicity and patients re-entering specialised services, together with subsequent increases in their use of primary care services.However, in this brave new world of innovation in pain services, questions remain as to how the ethics of new approaches will be taken into account and how we will ensure that patients continue to receive equitable and appropriate care, in a manner that they will best engage with. It would be a retrograde step to apply a utilitarian approachAccordingly, I encourage anyone conducting research to consider how it will apply in real time to patients and clinicians on the ground navigating their way through this new, unchartered and often digital, territory. By examining the utility of new interventions closely, and considering their long-term impact on our patient population, we can ensure that while we embrace new ways of thinking and technologies the people who need our help the most remain at the centre of our efforts.Paul CameronDivision of Population Health Science and Genomics, University of Dundee, UK; School of Medicine, Cardiff University, UK; NHS Fife Pain Service, Queen Margaret Hospital, Dunfermline, Fife, UK


There are an overwhelming number of patients suffering from low back pain (LBP) resulting from disc pathology. Although several strategies are being developed pre-clinically, simple strategies to treat the large number of patients currently affected is still needed. One option is to use concentrated bone marrow aspirate (cBMA), which may be effective due to its intrinsic stem cells and growth factors.Thirty-three patients who received intradiscal injections of cBMA to relieve LBP were followed up based on Numeric Rating Scale (NRS), Oswestry Low Back Pain Disability Index (ODI), and Short Form-36 Health Survey (SF-36) scores. Patients were also subdivided into those with a pre-injection NRS > 5 and pre-injection NRS ≤ 5. The proportion of patients demonstrating at least 50% improvement  from baseline at five follow-up visits for each outcome was evaluated.At least 50% improvement in NRS was observed for 13.8, 45.8, 41.1, 23.5, and 38.9% of patients across five follow-up visits, out to 1 year. When stratified by high (> 5) versus low (≤ 5) baseline NRS scores, the values were 14.3, 45.5, 71.4, 22.2, and 44.4% among those with high baseline pain, and 13.3, 46.2, 20.0, 25.0, and 33.3% among those with low baseline pain. The 50% improvement rates across visits were 4.3, 28.6, 30.0, 22.2, and 30.8% for SF-36, and 4.2, 26.7, 36.4, 55.6, and 30.8% for ODI.Intradiscal cBMA injections may be effective to reduce pain and improve function. Patients with relatively higher initial pain may have potential for greatest improvement. Low back pain (LBP) is among the most prevalent and costly of musculoskeletal disorders. Greater than 80% of the U.S. population has at least one episode of LBP and the associated costs due to medical expenses and lost wages can exceed $100 billion annually . LBP is The IVD is comprised of an outer annular fibrosis (AF) and inner nucleus pulposus (NP). The AF is composed of concentric, dense lamellae of highly extracellular matrix-oriented type I & II collagen fibers while the NP is a less structured gelatinous extracellular matrix rich in proteoglycans (including aggrecans) and type II collagen –6. Disc The use of point-of-care autologous therapies, namely platelet-rich plasma (PRP) and bone marrow aspirate (BMA)-derived therapies (commonly referred to as bone marrow aspirate concentrate (BMAC), bone marrow concentrate (BMC), or concentrated bone marrow aspirate (cBMA)) have been demonstrated to be a means to decrease pain for a wide variety of orthopedic applications –17. ThesThe preliminary PRP and cBMA injection studies have demonstrated promising potential to alleviating discogenic pain as a safe alternative for LBP relief –25. For Each patient displayed objective findings of discogenic degenerative changes via MRI evidence which included disc desiccation, disc bulge or small contained protrusion (> 6 mm), and/or posterior annular tear . Patients selected as candidates for treatment also had ≥50% disc height retained compared to other lumbar discs that were considered normal. The presence of Modic changes were not considered within our patient selection. By history, patients had subjective findings consistent with chronic discogenic LBP. Pain was reported with positions and/or activities such as sitting, bending, lifting and/or transitioning from sit to stand, or maintaining a forward flexed position at the waist. Patients reported that LBP was greater than radicular symptoms (if they had any). Physical exam findings included: reports of low back pain with range of motion (forward flexion > extension), normal neurological exam .Provocative discography was performed on all patients to confirm discogenic pain and internal disc disruption. All discograms were performed by a single physician (MWW), by SIS standard guidelines  using a Study procedures were approved by the Honor Health Institutional Review Board . Patients were identified by retrospective review of medical records between April 2010 and April 2015 and included those with chronic low back pain, confirmed to be discogenic in etiology. All patients had a long history of chronic LBP, typically greater than 1 year. All patients had a history of extensive conservative therapy without significant long-term benefit prior to intradiscal cBMA treatment including use of medications (NSAIDs and/or narcotics), physical therapy, and injections . A total of 33 patients who were treated during this time frame were reviewed   was used as necessary to ensure patient comfort during the procedure. Local anesthesia using 2% lidocaine was used superficially and to the level of the periosteum overlying the Posterior Superior Iliac Spine (PSIS). This was completed using a 27-gauge 1.5-in. and/or 25-gauge 3.5-in. needle as necessary. An 11-gauge Jamshidi bone marrow aspiration needle was advanced through the anesthetized tissue under fluoroscopic guidance until contact was made with the periosteum of the PSIS. The needle was advanced through the cortex of the PSIS and into the trabecular bone. Similar to previously described “aspirate-rotate-aspirate” protocols , 31, 52 Each target disc was identified under fluoroscopy using T12 as a reference. Superficial tissue was anesthetized to the level of the superior articular process with 1–2 ml of 1% preservative-free lidocaine. A standard, two-needle technique using an 18-gauge skin needle and a 22-gauge intradiscal needle was fluoroscopically guided in a right or left extra-pedicular approach to place the needle tip into the nucleus of the disc. Proper placement was confirmed in two planes  and pictures of final placement were printed. A predetermined volume of cBMA (3 ml or less) was injected intradiscally. After cBMA injection, needles were removed carefully, and bandages and pressure were applied to the injection site(s) under sterile conditions.Patients underwent an examination including the Oswestry Low Back Pain Disability Index (ODI) Questionnaire, Short Form-36 (SF-36) Health Survey, and Numeric Rating Scale (NRS) assessments pre-injection, and at 2, 6–8, 12, 24, and ≥ 52 weeks post-treatment.n = 15) and ≤ 5 (n = 18) and was incorporated into analyses depicting ≥50% change for each outcome  was used for all analyses. The effects of cBMA on NRS, SF-36, and ODI measures were evaluated using categorical analysis to examine the proportion of patients experiencing ≥50% change  in NRS, SF-36, and ODI over time in accordance with baseline pain levels Fig. . The proome Fig. . A serien = 8), 2 (n = 16), or 3 (n = 9) levels  pre-injection was 5.2 (± 0.4). The percentage of patients with at least 50% improvement in NRS scores at each post-injection time point  was 13.8% (1.2–26.3%), 45.8% (25.9–65.8%), 41.1% (17.8–64.6%), 23.5% (3.4–43.7%), and 38.9% (16.4–61.4%) at pre-injection, and at 2, 6–8, 12, 24, and ≥ 52 weeks post-treatment, respectively  pre-injection was 53.4 ± 2.6). The percentage of patients with at least 50% improvement in SF-36 scores at each post-injection time point  was 4.3% 0.0–12.7%), 28.6% (4.9–52.2%), 30.0% (1.6–58.4%), 22.2% (0.0–49.4%), and 30.8% (5.7–55.9%) at pre-injection, and at 2, 6–8, 12, 24, and ≥ 52 weeks post-treatment, respectively  pre-injection was 36.7 (± 2.6). The percentage of patients with at least 50% improvement in ODI scores at each post-injection time point  was 4.2% 0.05–12.2%), 26.7% (4.3–49.0%), 36.4% (7.9–64.8%), 55.6% (23.1–88.0%), and 30.8% (5.7–55.9%) at pre-injection, and at 2, 6–8, 12, 24, and ≥ 52 weeks post-treatment, respectively  vs. high baseline pain .In secondary analyses, improvement scores were examined stratified by low baseline pain , the major finding herein is that intradiscal injections of cBMA have the potential to reduce pain with a concomitant increase in overall patient health and function. Additionally, patients with higher baseline pain improved the most, which seems logical given that these patients had the greatest room for improvement.This retrospective analysis has obvious limitations such as the lack of a control group, possible regression to mean, and incomplete patient data at certain time points. Thus, the interpretation of these results should be considered with prudence. Injections of concentrated Bone Marrow Aspirate were offered as a treatment option for qualified patients based upon clinical evaluation, the refractory and somewhat degenerative nature of their condition, and the relative absence of effective conservative rehabilitation strategies to avoid surgical intervention. Sub-stratification of internal disc disruption correlating to subjective response was not performed because multiple levels were treated, each with their own respective pathology. The presentation of this retrospective data was designed to report the clinical outcomes of a single physician, nonetheless it is useful to consider the similarities between these results and other larger prospective studies where cBMA and/or PRP were used to treat LBP –27. For An interesting similarity to note is the apparent decrease in clinical effect around the 1-year mark for both this study and Pettine et al. . Since eThere are several potential mechanisms that may explain these observed clinical improvements. An obvious contender would be that the addition of anabolic growth factors and regenerative stem cells to the degenerate IVD could offset its catabolic environment. Increased levels of growth factors and cytokines within PRP have been shown to improve AF and NP cell proliferation, increase glycosaminoglycan content and collagen synthesis, and stimulate gene expression for extracellular matrix proteins critical for IVD function , 39, eveThe development of therapies such as autologous cBMA to treat the IVD and discogenic pain would be advantageous to treat the large number of individuals affected by this pathology. Additional studies are necessary to identify which subset of patients with discogenic LBP are most likely to experience the highest and most consistent benefits from this minimally invasive autologous therapy, and how effective this therapy is when compared to control therapies. In the future we hope to report these results, however this retrospective analysis supports the contention that autologous based therapies, including cBMA, are a logical strategy to alleviate discogenic pain and restore patient function. The use of autologous cBMA or other autologous growth factors represents a paradigm shift not just aimed at mitigating symptoms, but with the goal of providing a restorative therapy which provides long-term benefits of reduced pain and improved disc health and function.Additional file 1: Figure S1. (A) Proportion and 95% confidence intervals of patients with Numeric Rating Scale (NRS) score improvements of at least 30%. Proportions at each post-injection time point were 17.2, 54.2, 52.9, 41.2, and 44.4%, respectively. (B) Estimated NRS MCID of 2 points for patients reporting at least 30% improvement in pain scores. Proportions at each post-injection time point were 17.2, 45.8, 47.1, 35.3, and 38.9%, respectively. Visits are defined as follows: visit 1 (2 wks), visit 2 (6–8 wks), visit 3 (12 wks), visit 4 (6 mo), visit 5 (≥ 1 yr). The number of patients (N) with follow up data is listed below visit number. Figure S2. (A) Proportion and 95% confidence intervals of patients with Short Form-36 Health Survey (SF-36) score improvements of at least 30%. Proportions at each post-injection time point were 4.4, 35.7, 30.0, 44.4, and 30.8%, respectively. (B) Estimated SF-36 MCID of 18 points for patients reporting at least 30% improvement in pain scores. Proportions at each post-injection time point were 4.4, 35.7, 30.0, 44.4, and 38.5%, respectively. Visits are defined as follows: visit 1 (2 wks), visit 2 (6–8 wks), visit 3 (12 wks), visit 4 (6 mo), visit 5 (≥1 yr). The number of patients (N) with follow up data is listed below visit number. Figure S3. (A) Proportion and 95% confidence intervals of patients with Oswestry Low Back Pain Disability Index (ODI) score improvements of at least 30%. Proportions at each post-injection time point were 8.3, 46.7, 45.5, 66.7, and 38.5%, respectively. (B) Estimated ODI MCID of 12 points for patients reporting at least 30% improvement in pain scores. Proportions at each post-injection time point were 8.3, 26.7, 45.5, 77.8, and 30.8%, respectively. Visits are defined as follows: visit 1 (2 wks), visit 2 (6–8 wks), visit 3 (12 wks), visit 4 (6 mo), visit 5 (≥1 yr). The number of patients (N) with follow up data is listed below visit numberAdditional file 2. Supplementary Dataset.


Flatfoot is a common deformity in the pediatric population and has a multitude of causes. Sometimes, it can be a normal finding in children, and treatment should not be guided only based on the appearance, but rather after thoroughly assessing the patient and the impact it has on the child’s daily life. In this paper, we describe the quality of life that the patients are experiencing after the surgical treatment of this pathology. We made a comparison between the most used techniques for correcting flatfoot and insisted on the postoperative comfort of the patient, rehabilitation, and the time it took to get back to their daily routine. The comparison was made between Mosca calcaneal lengthening osteotomy, Grice extraarticular arthrodesis, arthroereisis and triple arthrodesis of the foot. All of the surgeries were performed by the same doctor at “Grigore Alexandrescu” Emergency Hospital for Children in Bucharest. From the data collected, we propose that newer, minimally invasive techniques could be used in treating this pathology in order to help the patient feel better in the postoperative period and avoid some of the complications regularly encountered when using the old techniques. Foot deformities are among the most frequent reasons children are brought to the Outpatient Department (OPD) for assessment, flatfeet being the main deformity responsible for these visits . From toMost of the children diagnosed with flatfoot can have a normal life without any complaints. Even if the deformity is quite severe, conservative treatment is the only option if there is no functional impairment or pain. Surgical procedures are indicated when the deformity is preventing the patient from living a comfortable life. Since we are dealing with pediatric patients, sports activities are a crucial part of their lives not only for normal growth and development but also for social reasons. Hence children need to be as active as possible. Sometimes, flat feet can keep these individuals from participating in these activities, mostly because of pain, deformity, and general poor function . SurgeryThe general consensus is that flat feet are diagnosed when the medial arch of the foot is dropped to a certain degree , 2 whileIn our center, the most used techniques are Mosca calcaneal lengthening , 13, GriWe assessed 39 patients that underwent a total of 70 surgeries from 2015 to 2020. The procedures listed are Mosca calcaneal lengthening, Grice extraarticular subtalar arthrodesis, triple arthrodesis of the foot, and subtalar arthroereisis. Of the 39 patients, 26 were boys and were 13 girls, with ages ranging from 9 to 17 years old. Out of these patients, 31 were diagnosed with bilateral flatfoot, 2 had unilateral right foot involvement, and 6 had unilateral left foot involvement. All of the patients diagnosed with bilateral flatfoot had the same surgical procedure done for both feet. From the 70 procedures that we performed, none was revision surgery. The procedures were divided as follows: 31 arthroereisis procedures, 21 Mosca, 16 Grice, and two triple arthrodeses. The procedures the paper is referring to are the ones performed to the feet; procedures done in conjunction with the main technique like bone graft harvesting and muscle procedures were not included. For example, we regard as one surgery when talking about the Grice procedure, and we are considering the bone harvesting and Achilles tendon lengthening surgery as a separate procedure; the same goes for Mosca when excluding iliac bone harvesting and Achilles tendon lengthening. All of our patients underwent these procedures before the foot surgery itself when choosing the Mosca or Grice protocols. These steps are mandatory for the main procedure to be carried out. Regarding complementary procedures for triple arthrodesis and arthroeresis, we have done an Achilles lengthening surgery if needed. The data collected comprised information about age, sex, unilateral or bilateral involvement, days of admission in the hospital, admission to the ward or Intensive Care Unit (ICU), unilateral or bilateral procedure, postoperative casting, associated comorbidities, postoperative complications and complains, and postoperative medical treatment. In addition to hospital and surgery topics, the study focused on the time patients need to begin normal activities, like full weight-bearing, participating in sports and social activities, days necessary for pain suppression therapy, and general comfort after the procedure.Before the treatment plan was decided upon, we started patient evaluation with a complete clinical examination followed up by a radiologic assessment to confirm the diagnosis. The main clinical landmarks for flatfoot identified were: a drop of the medial arch, valgus deviation of the heel both plantigrade and while walking on tiptoes, modifications of medial and lateral borders of the foot, pressure sores, joint hyperlaxity and pain around the feet and legs during physical activity. All of these clinical findings were evaluated before and after surgery. The primary consideration that we centered upon was pain; it was the most important finding in deciding the treatment protocol, and it was decided to choose the surgical treatment if conservative management did not improve the patient’s condition. All of the patients had a collapsed medial arch, rigid hindfoot valgus, and a convex medial border. The most important clinic criteria for surgery was pain around the feet and lower legs, varying in intensity based on activity levels and severity of the deformity. Most of the patients were complaining of pain after moderate physical exercises that were keeping them from participating in normal or competitive social activities. Few patients developed callosities in critical areas that were painful after mild physical activities like short walks in the park or doing housework. According to the Wong-Baker pediatric pain scale -19, the Radiologically, full weight-bearing X-rays of the feet in frontal and coronal views were performed. On the lateral view, the Meary angle, talocalcaneal divergence, calcaneal pitch and cyma line were evaluated. On the frontal view, the talocalcaneal angle, the talonavicular coverage angle, and the talar- first metatarsal angle were evaluated. All of the measurements were done before and after surgery in order to evaluate the degree of correction. Besides pain, that was the main issue both pre- and postoperatively, other critical factors were postoperative hospitalization days, postoperative medical treatment and the time that was required for the patients to get back to their daily routines. We evaluated the number of days that the patients stayed in the hospital postoperatively, both on the ward and in the ICU, how long was the time frame that they needed pain suppression therapy, and for long did they require antibiotic therapy.After evaluating the 39 patients that underwent different reconstructive procedures, the general conclusion was that performing older techniques is more time consuming for the medical team and much more stressful for the patients. At the one-year follow-up, the results were comparable regarding clinical and radiologic evaluation, with no significant differences in regard to function and activity level when comparing the procedures listed. However, achieving this comfortable status was more challenging for some patients than others, and the chosen technique had a significant impact. Procedures like calcaneal lengthening and Grice implied that the patient required longer periods of hospitalization, more days of physiotherapy, a higher risk for intraoperative and postoperative complications with more inferior aesthetic results due to multiple site scarring. On the other side, a more minimally invasive technique like arthroereisis achieved the same results but implied shorter hospitalization, less pain, better comfort and aesthetic results regarding scarring. Probably the most important advantage for this procedure is that since it is atraumatic with the anatomical structures of the ankle and subtalar joint, the surgeon can perform it bilaterally, allowing the patients to avoid a second visit to the hospital and undergo another surgery.Looking back at the data and assessing every subgroup in detail, relevant judgments were made by considering every procedure that was done. By far, the most uncomfortable procedure for the patients was the Mosca technique . About 5 to 7 days of hospital stay were needed for the patients to feel comfortable and safe to go back home; most of the discomfort was due to the pain associated with bone grafting (16 patients) and the calcaneal osteotomy (13 patients). Because the patients were in discomfort, physiotherapy was initiated later  and the time they needed to get back to their normal lives (around 10 weeks for painless full weight-bearing). Also, in some cases, pain suppression therapy had unpleasant side effects like nausea, dizziness and lethargy.The Grice procedure, on the other hand, was better tolerated by the patients, and pain management was a lot easier since the procedure itself is less invasive than others. The only problems that patients were complaining about were scarring in a very limited region (8 patients) and neurologic deficits because the peroneal nerve can get irritated during graft harvesting (4 patients). Patients were feeling better about the procedure and regained full weight-bearing faster compared to the Mosca and triple arthrodesis procedures, but much slower compared to arthroereisis. Also, hospital admission days were fewer in number thanks to better pain management and shorter postoperative care.Arthrodesis was easier to tolerate than Mosca and Grice procedures because scarring was minimal - only arthroereisis showed better results in this regard. Postoperative pain was easily managed, and because no other procedures were associated, it was easier for the patients to recover. The standard protocol of 6 weeks non-weight bearing interval was prescribed, and rehabilitation was done without complications. All of the patients involved had neurologic disorders; therefore, other joint sparing procedures were not indicated since the risk of relapse is very high.Looking back at the arthroereisis procedure and comparing it to the other ones, it should be said that it was the most pleasant out of the 4 for the patients to go through. One of the most important elements to consider while treating patients this way is that the procedure can be done bilaterally, avoiding further hospital admission. In general, the patients stayed about 48 hours in the hospital for the procedure compared to 5-7 days when performing unilateral Mosca, Grice, or triple arthrodesis procedures. Getting back to normal activities and painless full weight-bearing was noted about 10 days postoperatively in cases where a percutaneous Achilles tendon surgery repair was not performed, and 4 weeks if the lengthening was mandatory. Pain treatment was administered for shorter periods, and the aesthetic results were the best since scarring is minimal.There are several options for treating flatfoot in symptomatic patients, and the choice for the procedure is up to the surgeon who has to consider multiple factors. The main problem with this pathology is not the aesthetic issue that the parents and, sometimes, the patients are referring to, but how the foot performs during activity, pain being the biggest complaint. The amount of pain depends mostly on an underlining pathology or type of physical activity. Professional athletes are complaining more about pain than children who occasionally participate in sports activities. Looking back at the study group, it is safe to say that doing less invasive techniques like arthroereisis can be a valid option for treating painful flatfoot. We can conclude that using this procedure for patients who do not have an underlining pathology and are involved in sports activities can consistently improve their daily lives without the drawbacks of major surgeries like Mosca and Grice. Furthermore, given the fact that Achilles tendon lengthening surgery is not mandatory, casting can be avoided until full weight-bearing is resumed. Other considerations in favor of this procedure are better aesthetic, fewer pain medications, reduced risk of feet infection, reduced infection risk if other surgeries are performed, and a much shorter rehabilitation period after surgery. One key consideration in promoting arthroereisis is that it leaves the option for the surgeon to do revision surgery without having to struggle with the sequelae of previous surgeries. It does not harm the bony structures since no bone is cut, and only the soft tissues around the subtalar joint are disrupted. In case of relapse, the procedure can be revised with a different type of implant, or the procedure can be converted to calcaneal lengthening or Grice procedure without having to deal with abnormal anatomy of the calcaneus or thallus. Subtalar arthroereisis is a viable procedure in its own rights, but the surgeon’s decision is the driving force when treating flatfoot, especially if the patient has an underlying pathology like cerebral palsy, fibular deficiency, tarsal coalition, severe joint hyperlaxity, or other collagen- related syndromes. It is a procedure reserved for painful flatfoot when patients do not have a local or general associated pathology, and it will not produce the desired results in complex cases.The authors declare that there is no conflict of interest.


Moderate-to-severe postoperative pain following craniotomy has a high incidence in pediatric patients. Such pain may cause agitation, intracranial hypertension, epileptic seizures, and postoperative hematoma, which affect morbidity and mortality. Although scalp nerve block (SNB) achieves satisfactory pain relief except for suboccipital mid-craniotomy in adults and ropivacaine is widely used as a long-acting peripheral nerve block agent in children, there are few studies of SNB with ropivacaine in pediatric patients undergoing craniotomy. In addition, the neurosurgery operation time is relatively long, but the duration of action of SNB is limited. It is generally believed that postoperative SNB is better than preoperative SNB for postoperative analgesia. However, considering the concept of preemptive analgesia, we believe that preoperative SNB may achieve a longer postoperative analgesia effect than we expected.This trial is a single-institution, prospective, randomized, controlled, double-blind study. A total of 180 children aged between 1 and 12 years who are undergoing elective craniotomy will be randomly allocated in a 1:1:1 ratio to three groups: group B (preoperative ropivacaine block group), group A (postoperative ropivacaine block group), and group N (nonblocking control group). This randomization will be stratified by age in two strata (1–6 years and 7–12 years). The primary outcome is the total consumption of sufentanil within 24 h after surgery. The secondary outcomes include assessment of pain scores, total consumption of sufentanil and emergency-remedy medicine consumption at observation points, the occurrence of postoperative complications, and the length of hospitalization after surgery.This study is designed to explore the effect and feasibility of SNB with ropivacaine for postoperative analgesia in pediatric patients undergoing craniotomy. Further aims are to compare the effects of preoperative and postoperative SNB on postoperative analgesia in order to identify whether there is a preemptive analgesic effect and determine the better time to implement SNB in pediatric patients during craniotomy.ChiCTR1800017386. Registered on 27 July 2018.Chinese Clinical Trial Registry  Pain is defined as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage” according to the International Association for the Study of Pain (IASP) . Fetal pFor a long time, craniotomy procedures have been considered to be associated with less pain than other surgical procedures; accordingly, fewer analgesic methods are implemented for craniotomies than for other surgical procedures . TherefoThe improper management of pain following neurosurgery may further result in severe consequences such as agitation, intracranial hypertension, epileptic seizures, and postoperative hematoma, which affect morbidity and mortality –15 and fRopivacaine, for long-action  and safeBecause pain is a subjective indicator and some children, particularly infants, cannot properly express their pain, it is more difficult to evaluate pediatric pain than adult pain –27. TherThe FLACC scale method is commonly used for pain assessment following pediatric surgery. In the FLACC scale, pain scores are obtained by medical staff based on the observed pediatric condition and contents of the quantification table. Each item is scored from 0 to 2 points. The sum of the content scores is the total score (from 0 to 10 points). A higher score indicates more severe pain. With the FLACC scale, physicians observe children for 1–15 min, and this tool is commonly used for the evaluation of postoperative pain in children aged 1–18 years and is the first evaluation method for hospitalized children.This scale is primarily applicable to children between 1 and 18 years of age and for infants or children with communication difficulties. The score ranges from 0 to 10 points. However, it should be noted that children may lose their “smiley face” because of fear, hunger, or other stressors. Therefore, the possible influences of these factors should be excluded from the pain assessment when using this scale.This scale ranges from 0 to 10 points. A score of 0 indicates no pain, scores of 1–3 indicate slight pain tolerable and does not affect rest, scores of 4–6 indicates that the pain affects sleep but is tolerable, and scores of 7–10 indicate that the pain is intolerable and affects appetite and sleep.This trial is a single-institution, prospective, randomized, controlled, double-blind study that is designed to explore the effect and feasibility of SNB with ropivacaine for postoperative analgesia in pediatric patients undergoing craniotomy. We further compared the effect of preoperative and postoperative SNB on postoperative analgesia in pediatric craniotomy. From July 2018 to October 2020, pediatric patients aged 1–12 years presenting for elective craniotomies will be recruited from Beijing Tiantan Hospital, Capital Medical University.The patient flow diagram of the study is presented in Fig. Trial investigators will identify consecutive eligible patients based on the inclusion and exclusion criteria the day before the operation. When patients meet the eligibility criteria, an investigator will explain the study protocol and relevant information to the authorized surrogates and participants. Informed written consent will be obtained from the authorized surrogates and participants (over 7 years) themselves, and then they will be instructed how to use the electronic analgesia pump.Age of 1–12 yearsAmerican Society of Anesthesiologists (ASA) physical status of I–IIICraniotomy for tumor resection includes frontal, temporal, parietal, and bifrontal regions.Inclusion criteria:Children with severe diseases or cardiac insufficiencyPresence of airway abnormalities and reactive airway diseasesChildren who cannot be weaned from endotracheal intubation following surgeryChildren with abnormal liver and kidney function test results Children who have participated in other clinical trialsChildren whose authorized surrogates are unable or unwilling to provide informed consent or poor complianceChildren who have mental illness or use antipsychotic drugs for treatmentPosterior fossa craniotomy for tumor resectionExclusion criteria:After meeting the eligibility criteria and signing the informed consent to participate in the study, 180 patients will be randomly allocated in a 1:1:1 ratio to three groups: group B (preoperative ropivacaine block group), group A (postoperative ropivacaine block group), and group N (nonblocking control group), stratified by age into two strata (aged 1–6 years and aged 7–12 years). The allocation schedule will be made with a computer random number list generated by Stata software version 15.1.Group B: Preoperative SNB group : SNB will be performed after general anesthesia and endotracheal intubation.Group A: Postoperative SNB group: SNB will be performed after the end of the operation, and the effects of analgesics and sedatives will not wane.Group N: nonblocking control group: This control group will not undergo SNB.The corresponding SNB schemes of the three groups will be the following:SNB will be performed exclusively by a well-trained anesthesiologist with two age-appropriate concentrations of ropivacaine: 0.3% in children aged 1–6 years and 0.5% in children aged 7–12 years.The site of SNB will be selected according to the craniotomy region. Dosage: supraorbital nerve (1–2 ml), auriculotemporal nerve (1–2 ml), zygomatic temporal nerve (1–2 ml), greater occipital nerve (2–3 ml), and lesser occipital nerve (2–3 ml). An experienced anesthesiologist will determine the injection points according to the surgical incision site. The total volume will not exceed 5 ml.The independent anesthesiologist performing the SNB will not be an investigator in charge of the operation and will not visit patients before or after the operation. The anesthesiologist will enter the operating room twice, the first time is after endotracheal intubation prior to surgery, and the second time is after suturing the scalp. He/she will confidentially perform or not perform SNB according to the allocation plan and cover the dressing at the corresponding portion to conceal the allocation. Due to ethical care standards for children, normal saline will not be injected, and only a dressing will be covered in group N.2), invasive arterial pressure, end-tidal carbon dioxide partial pressure (PETCO2), anesthesia gas monitoring). Midazolam (0.025–0.075 mg kg−1) and methylprednisolone (0.1–0.2 mg kg−1) will be received intravenously before anesthesia induction. A dose of 0.5 mg kg−1 midazolam will be administered orally to children in whom intravenous access cannot be established due to crying and agitation. Peripheral vascular access will be obtained after sufficient sedation, and anesthesia will be induced with 0.5 μg kg−1 sufentanil, 2–3 mg kg−1 propofol, and 0.1–0.2 mg kg−1 cis-atracurium or 0.4–0.6 mg kg−1 rocuronium. After intubation, mechanical ventilation will be in a volume-controlled mode with a tidal volume set at 8–10 ml kg−1, and the respiratory rate will be set at 14–20 breaths per minute. Total intravenous infusion anesthesia will be maintained with remifentanil and propofol (8 mg kg−1 h−1). The initial dose of remifentanil will be 0.1–0.2 μg kg−1 min−1, adjusted for analgesic needs during operation. The infusion of propofol and remifentanil will be stopped after surgery. Tramadol 1 mg kg−1 will be administered half an hour before the end of surgery. The mean arterial pressure (MAP) and HR will be maintained within 30% of the baseline values, and if exceeding this range, corresponding treatment will be taken. No other additional analgesics will be administered during surgery. The total dosage of analgesics and anesthetics will be estimated after surgery. Local infiltration of the head incision will not be performed before surgery. During the operation, the child’s temperature will be monitored and maintained at 35–38 °C. After extubation, patients will be transferred to the postoperative care unit (PACU) or ICU.On arrival to the operating room, standard monitoring will be established (noninvasive blood pressure (BP), heart rate (HR), pulse oximetry saturation  will be routinely applied. The electronic analgesia pump includes a bag loaded with 2 μg kg−1 orally. Information on whether additional analgesics will be needed within 3 days after surgery as well as on the drug dosage and frequency and the usage of the postoperative electronic analgesia pump  will be recorded.Administration of analgesics and remedies: Children who still show insufficient analgesia or discomfort after the operation and require analgesics will be administered acetaminophen at 15 mg kgPrimary outcome: Total consumption of sufentanil within 24 h after surgery.Assessment of postoperative pain scores at 1, 2, 4, 24, and 48 h after surgery: children aged 1–6 years: due to the special characteristics of children after neurosurgery and of preschoolers who cannot properly express their pain with language, two different scoring methods will be used—the FLACC scale and the FACES facial pain score. Children aged 7–12 years can use NRS for self-assessment in addition to the above two methods.Total consumption of sufentanil within 1, 2, 4, and 48 h after surgery and emergency-remedy medicine consumption at 1, 2, 4, 24, and 48 h after surgery.Postoperative safety indicators: complications including agitation, postoperative nausea and vomiting (PONV), bleeding, infection, hypoxemia, respiratory depression, neurological impairment at 1, 2, 4, 24, and 48 h after surgery, and serious adverse events including disability and death.Length of hospitalization after the surgery.Secondary outcomes:There will be no special criteria for modifying allocated interventions, but there are conditions under which to terminate the study: (1) unexpected postoperative continuation of intubation; (2) serious adverse events during the operation, such as acute massive hemorrhage, malignant fever, and shock; (3) unplanned reoperation within 24 h after surgery; (4) serious, adverse surgically related events/reactions occurring within 24 h after the operation, such as postcraniotomy hematoma, unconsciousness, coma, and cardiac arrest; and (5) serious adverse events/reactions related to the medicines in electronic analgesia pumps within 24 h after surgery.The anesthesiologist who performs the SNB is well skilled and will be trained to perform the standard intervention method. The anesthesiologists in charge will be blinded when he/she performs anesthesia and records the intraoperative data. The investigator group will be blinded and well trained to perform preoperative recruitment and postoperative follow-up. Nurses in the PACU, ICU, or ward will be trained on how to use the electronic analgesia pumps and when to press the button of the electronic analgesia pump . In addition, participants and authorized surrogates will also explain the usage of electronic analgesia pump. Any deviations and missing data will be recorded.After the patient’s enrollment, the independent anesthesiologist who performs the SNB will obtain the allocation randomized schedule from computer software operation. The allocation information of participants who are recruited and randomized will be placed in a sealed envelope and stored individually. Therefore, the anesthesiologist who performs the SNB will be the only person who knows the allocation schedule. This procedure ensures that both investigators and participants will not know the intervention.Patients, anesthesiologists in charge of operation, and investigators who are responsible for enrolling and observing the primary and secondary outcomes will not know whether the children will receive blocking. The blinding will be discontinued after all data collection is completed. Furthermore, serious life-threatening adverse events leading to prolonged hospital stay or death will be reported to the principal investigator (PI), and the blinding will be broken following consultation with the PI if necessary.Investigators will explain the benefits of participating in the trial to patients and their authorized surrogates before surgery. After the operation, a specific blinded investigator will conduct follow-up in the ward at 1, 2, 4, 24, and 48 h. Participants who are unable to complete the assessment of the primary outcome will be excluded in situations such as death or discharge in 24 h. Cases with other deviations and deficiencies except for the aforementioned conditions will be retained. Outcome investigators will receive training on all outcome measures. Nurses, children, and their authorized surrogates will be trained to use the electronic analgesia pump. All electronic analgesia pumps will be calibrated by a researcher according to uniform standards. The anesthesiologists in charge will record the patients’ intraoperative data. The relevant data of the electronic analgesia pumps will be recorded by an electronic memory system. The data are accessible to investigators who are blinded to the trial. A blinded investigator will collect other data on secondary outcomes, such as pain scores, postoperative complications, and length of hospitalization after surgery. The data managers will use double data entry to enter data into the EpiData database. An inspector will examine the data, create records, and revise these records as necessary.Each participant will have a unique study identifier, and their data will be recorded by an independent data manager. The data will be electronically stored in the EpiData database and undisclosed to other researchers until the study is completed. The final dataset will be handed over to statistical analysts for statistical analysis. Regular data checks and double data entry will be applied to promote data quality.Before the trial, all personal information will be obtained only by the PI who has signed a confidential disclosure agreement. After randomization, during and after the trial, unique study identifiers will be assigned to each participant to reduce the risks of accidental disclosure of identifiable information. To protect confidentiality, paper information will be stored in a locked cabinet inside the locked research office. The electronic information will also be kept in a password-protected electronic database. The specific privilege assignments to access the database to acquire personal information will be limited by the role of the assignees in the trial. Only code numbers will appear on any data and documents used for evaluation or statistical analyses.α level of 0.017 (0.05/3) and 80% power. Considering a 10% rate of loss to follow-up, it would be necessary to include 60 participants per group . The sample size calculation is performed using PASS 15.0.The primary outcome in this study is the total consumption of sufentanil within 24 h after surgery. A decrease of 20% will be considered a minimal clinically important difference. According to Maxwell’s article  and our t test or analysis of variance (ANOVA). For abnormally distributed and unequal variance data, statistical analyses of categorical variables will be carried out using a nonparametric test as appropriate. A chi-square test and Fisher’s exact test will be used to compare proportions. For the primary outcome, we will first use ANOVA to compare whether there are differences among the three groups. If there are differences, further multiple comparisons will be performed. The results of the FLACC scores, FACES scores, and NRS scores will be analyzed by repeated measurements for general linear models and multivariate analysis. We will also perform the subgroup analysis based on different ages. We will exclude patients who reject the intervention and whose primary data are missing. Statistical significance will be defined as a P value < 0.05.Statistical analyses will be performed using SPSS 23.0 software. All measured data will be reported as the mean ± standard deviation . The results will be disseminated to all participants, researchers, and healthcare providers through study summary documents, courses, presentations, and the Internet. The datasets analyzed during the current study are available from the corresponding author on reasonable request.All pediatric patients who undergo craniotomy require analgesic medications for postoperative analgesia. SNB is a simple strategy that can relieve postoperative pain. In this trial, we hypothesize that ropivacaine, which is the SNB administered in pediatric patients undergoing neurosurgery, will decrease the requirement for sufentanil and other pain medications as well as reduce postoperative pain scores. The second aim is to determine whether preoperative block or postoperative block is more suitable for postoperative pain control. This study will be a prospective, randomized, controlled, double-blind study. Participants are randomized into three groups: preoperative SNB group, postoperative SNB group, and nonblocking control group, who will be followed for 48 h postoperatively and then the day of discharge. We have set the same standardized anesthesia protocol to avoid sources of bias and will use the FACES facial pain assessment method based on the FLACC scale to improve the accuracy of pain measurement. The study will be carried out at Beijing Tiantan Hospital, Capital Medical University (which has the highest rank for neurosurgery in China). This investigation is a single-center study, which may bias our results. However, the results of this study may promote the development of postoperative analgesia and popularize the optimal pain management of children.The version number of this Clinical Research Program is V2.0, and the version date is 20180830. The first patient was recruited on September 13, 2018. Recruitment is expected to end in October 2020.Additional file 1.


Background and objectives: Non-motor symptoms in the form of increased sensitivity are often associated with the onset of idiopathic Bell’s palsy (IBP). The aims were to determine whether the pain threshold in the retroauricular regions (RAR) in IBP patients and the time of its occurrence is related to IBP severity. Materials and Methods: The study was conducted among 220 respondents ). The degree of IBP was graded using the House–Brackmann and Sunnybrook Grading Scales , whereas the pain thresholds were measured using the digital pressure algometer. Results: We found no difference in the degree of the pain threshold between the right and left RAR in the HS group. IBP patients belonging to groups II, III, IV, and V had lower pain thresholds in both RARs than HS and IBP patients belonging to group VI. There was no difference in the degree of pain threshold in RAR between the affected and unaffected side in IBP patients. The incidence of retroauricular pain that precedes paralysis and ceases after its occurrence in groups II and III of IBP patients is noticeably lower and the incidence of retroauricular pain that occurred only after the onset of paralysis is more frequent. Also, we found that the incidence of retroauricular pain that precedes paralysis and ceases after its occurrence in groups V and VI of IBP patients was more frequent. Conclusions: The degree of pain threshold lowering in RAR  is inversely related to the severity of IBP. We suggest that the occurrence of retroauricular pain before the onset of facial weakness is associated with higher severity of IBP while the occurrence after the onset is associated with lower severity of IBP. The facial nerve (FN) provides innervation to the mimic muscles of the ipsilateral half of the face, the posterior belly of the digastric muscle, stapedius, and stylohyoid muscles. It is mainly a motor nerve, but it also contains sensory and parasympathetic fibers that constitute the intermediate nerve which provides taste sensation from the anterior two-thirds of the tongue; enables secretory and vasomotor fibers to reach the lacrimal, submandibular, and sublingual salivatory glands, as well as transmits cutaneous sensory impulses from the external auditory meatus and retroauricular region (RAR) ,2.Both inflammatory edema in the FN and a vasospasm of the stylomastoid artery are shown to decrease blood supply ,4 and reIBP has different path stages including acute stage 1–7 days), resting stage (8–20 days) and restoration stage (21–90 days)  days, re. In addiThe pathogenesis of RAP in these patients is not entirely clear . With redetermine whether the pain threshold in the RARs in patients with IBP is related to IBP severity;determine whether the time of RAP occurrence is prognostic for IBP severity.The aims were to:This study was conducted at the Clinic for Neurology, Clinical Center of Vojvodina, in the period from October 2018 to June 2020. The study was conducted in accordance with the Declaration of Helsinki, and the protocol was approved by the Ethics Committee of Clinical Center of Vojvodina .All the patients affected by facial paralysis that reached the neurology department of our hospital have been evaluated. After a detailed neurological examination, we exclude central nervous system involvement. Magnetic resonance imaging of the brain and/or magnetic resonance angiography were performed when clinical history or clinical signs suggested a secondary facial palsy.The patients included in this study group met the following criteria:patients with unilateral IBP , 10th Revision);acute phase of IBP (within 7 days from onset) ..27].2, connected to a computer via a pressure transducer. In the course of the examination, the tip of the device is placed perpendicular to the trigger point, and the patient is required to press a button at the slightest feeling of pain, which will register the values via a USB unit, in real time [2.Pain threshold value was determined using the digital pressure algometer. The digital pressure algometer is a standardized device for objectively quantifying a pressure pain threshold. The device is gun-shaped with a rubber flat tip having an area of 0.5 cmeal time . The paieal time , minimiz® Statistics 20.00  and R Core Team (2020) version 4.0.3. . Descriptive and physiological data are expressed as mean ± SD. Statistical significance was determined at the alpha level of 0.05. Also, normal distribution of the variables was assessed using the Shapiro–Wilk test. To compare pain threshold among the six groups, we used one-way analysis of variance (ANOVA), followed by a post hoc analysis (Tukey’s Honestly Significant Difference). Pain threshold among patients regarding the affected side was assessed by the two-way ANOVA . To show a statistically significant difference between the groups of patients with IBP (degree of damage) in terms of frequency of pain, we use Pearson’s Chi-squared test.The data analysis was conducted using SPSSThe present study comprised 220 respondents, of whom 142 are patients affected by IBP  and 78 expressed as HS grade . No significant difference in the group of IBP patients has been noted between male/female or left/right side incidence of palsy.2, while in the left RAR is slightly higher and amounts to 466.66 ± 91.53 kPa/cm2. There is no statistically significant difference in the degree of the pain threshold between the right and left RAR. The average pain threshold in both sides in HS is 464.45 ± 85.50 kPa/cm2.The average pain threshold in the right RAR in the group of HS is 462.25 ± 84.87 kPa/cm2 in group II, 181.34 ± 23.32 kPa/cm2 in group III, 282.93 ± 55.98 kPa/cm2 in group IV, 382.00 ± 41.57 kPa/cm2 in group V, whereas it was 429.44 ± 43.73 kPa/cm2 in group VI. Pain threshold values in the RAR-affected side in the group of HS and patients with IBP, and post hoc p values among the groups revealed by the one–way ANOVA are presented in Pain threshold values in patients with IBP on the affected side were 192.01 ± 22 kPa/cm2, in III group is 219.27 ± 31.23 kPa/cm2, in IV group is 316.44 ± 76.63 kPa/cm2, in V group is 423.00 ± 18.94 kPa/cm2 while in VI group is 474.02 ± 36.28 kPa/cm2. Pain threshold values in patients with IBP in the RAR-affected side and healthy side, as well as p-values among the groups revealed by two-way ANOVA are presented in Pain threshold values in patients with IBP on the healthy side in II group are 225.21 ± 28.43 kPa/cmIn our series of patients with IBP, RAP was present in 57.7% of the whole study group. RAP preceded the onset of the palsy in 26.8% of cases, while after the onset of palsy it occurred in 17.6% of cases. The presence of RAP in examined groups of patients with IBP at different stages of IBP are presented in p-value < 0.001).Using Pearson’s Chi-squared test, we showed that there is a statistically significant difference between the groups of patients (degree of damage) in terms of frequency of pain  of RAP that precedes paralysis and ceases after its occurrence in groups II and III of patients with IBP (0% and 8.6%) is noticeably lower than expected frequencies  and that the incidence of RAP that occurred only after the onset of paralysis (46.2% and 31.4%) is noticeably more frequent than the expected frequency.The results also showed that the incidence of RAP that precedes paralysis and ceases after its occurrence in groups V and VI of patients with IBP (42.4% and 64.3%) is more frequent than expected. Although the incidence of RAP that occurred only after the onset of paralysis (6.1% and 0%) is not statistically noticeably less frequently than expected, there is a trend which suggested that if we increase the number of the respondents the incidence will be statistically noticeably.In group IV patients with IBP, we did not prove a statistically significantly lower or more frequent frequency of RAP than expected.In the groups of IBP patients in which pain was presented before and after the onset of the paralysis as well as in the groups of IBP patients in which the pain was never presented, we did not prove a statistically significantly lower or more frequent frequency than expected.Jong and colleagues demonstrated that patients with a higher degree of IBP have a higher degree of FN damage ,30.RAP in patients with IBP has also been described by other studies ,15,19. FFN is richly innervated by their nerves, NN, that have nociceptive function. Stimulation of NN dominating in FN trunk can be transmitted to trigeminocervical nuclear complex and make referred pain in the craniofacial region segmentally. The reason why referred pain of FN origin develops around the ear is that FN and its unsheathed connective tissue are derivatives of the second branchial arch, which is homologous with the somites of the body .The fibers of these tiny nerves belong to group A Delta ,32, whicHowever, in the more severe cases of IBP, neurotmesis can occur besides neuropraxia and axonotmesis. Consequently, it is manifested by the micro-necrosis of NN, the termination of conduction of afferent impulses, and the absence of RAP and eventually causing the more severe FN damage. After being damaged, fibers will not transmit efferent impulses and innervate mimic muscles, but neither will they transmit afferent impulses leading to RAP. There is a disproportion between the current pain sensation and the degree of muscle loss, whereas the pain that occurs before the onset of facial paralysis indicates not only the latent period of NN injury but also the onset of more severe forms of IBP ,36,37.Based on the findings of this study, we suggest that the occurrence of retroauricular pain before the onset of facial weakness is associated with a higher severity of IBP, while the occurrence after the onset of weakness is associated with lower severity of IBP. We can explain these results by the fact that the FN fibers and NN in patients belonging to groups II, III, IV, and V are still able to convey impulses in both afferent and efferent directions, and therefore the occurrence of RAP after the onset of the paralysis cannot reliably ascertain the more severe degree of FN damage ,15,16,17Patients belonging to groups II, III, IV, and V also had a statistically significantly lower pain threshold in the RAR side, opposite to the paresis, compared to HS and patients belonging to group VI. This phenomenon, when the patients sense pain in the contralateral side, is known as mirror-image pain. Pathogenesis of mirror-image pain is still not exactly known, but there are some possible signaling mechanisms in the contralateral reaction of the nerve tissue after unilateral nerve injury ,39,40. IIn this study, we obtained results that there is pain (referred pain), a lowered pain threshold on the damaged side and on the opposite, motor healthy side. In this conversation, we could call it a “mirror image lowered pain threshold”, or simply “mirror lowered pain threshold” ,39,40.In this study, we found no difference in the degree of the pain threshold between the right and left RAR in the group of HS. Patients with Bell’s palsy belonging to groups II, III, IV, and V had lower pain thresholds in both RARs than HS. We also found no difference in the degree of the pain threshold in both RARs between HS and patients belonging to group VI. The degree of pain threshold lowering in RAR  is inversely related to the severity of IBP. There was also no difference in the degree of pain threshold in RAR between the affected and unaffected side in the group of patients with IBP. The incidence of RAP that precedes paralysis and ceases after its occurrence in groups II and III of patients with IBP is noticeably lower and the incidence of RAP that occurred only after the onset of paralysis is more frequent in our study. The results also showed that the incidence of RAP that precedes paralysis and ceases after its occurrence in groups V and VI of patients with IBP was more frequent. We suggest that the occurrence of retroauricular pain before the onset of facial weakness is associated with a higher severity of IBP, while the occurrence after the onset of weakness is associated with lower severity of IBP.


Pain, insomnia and stigma were the most prevalent NMS and HRQoL was significantly impaired in CD patients compared to HC. There was strong correlation of NMS burden with HRQoL  in CD patients. Regression analysis between HRQoL and NMS suggested that emotional well-being (standardized beta = − 0.352) and pain (standardized beta = − 0.291) had a major impact on HRQoL while, in contrast motor severity had no significant impact in this model. Most NMS with the exception of pain, stigma and ADL did not correlate with motor severity. NMS are highly prevalent in CD patients and occur independent of age, sex, disease duration, duration of botulinum neurotoxin therapy and socio-economic status. Specific NMS such as emotional well-being and pain have a major impact on HRQoL and are more relevant than motor severity.Non-motor symptoms (NMS) occur in patients with cervical dystonia (CD) but with variable frequencies and impact on health-related quality of life (HRQoL). To define non-motor and motor profiles and their respective impact on HRQoL in CD patients using the newly validated Dystonia Non-Motor Symptoms Questionnaire (DNMSQuest). In an observational prospective multicentre case–control study, we enrolled 61 patients with CD and 61 age- and sex-matched healthy controls (HC) comparing demographic data, motor and non-motor symptoms and HRQoL measurements. 95% CD patients reported at least one NMS. Mean total NMS score was significantly higher in CD patients (5.62 ± 3.33) than in HC (1.74 ± 1.52;  Cervical dystonia (CD) is the commonest idiopathic focal dystonia  .Motor assessment: Toronto Western Spasmodic Torticollis Rating Scale (TWSTRS)  Guy  to assesNon-motor assessment: Dystonia Non-Motor Symptoms Questionnaire (DNMSQuest) with seven different domains: sleep, autonomic symptoms, fatigue, emotional well-being, stigma, ADL, sensory symptoms ; Quality of life questionnaires: Craniocervical dystonia questionnaire (CDQ-24) . All participants provided written informed consent before any study procedure was performed. The following variables were collected:U Test. Analyses were performed with Chi-Square-Test and with Spearman rank correlation coefficient (r). The correlation was considered: “weak” if the r value was < 0.3, “moderate” if 0.3–0.5, “high” if > 0.5. A p value of less than 0.05 indicated statistical significance. Based on the approach of van den Dool et al. .CD patients had a mean TWSTRS sum score of 34.5 ± 12.94 (range 9.5–65.5) and a mean UDRS sum score of 9.5 ± 2.81 (range 1.5–14.0). CD patients ranged from CGI score 2–7 with 77% of patients presenting with “mildly ill” (score 3) to “markedly ill” (score 5) . In contrast, 92% of HC reported to be “normal, not at all ill” in the CGI score . Based on the Col-Cap concept Reichel , only 6.p < 0.001). 95.1% CD patients reported at least one NMS and therefore only 4.9% did not suffer from any of the assessed NMS. About 29.5% CD patients presented with at least eight NMS. Additionally, all DNMSQuest domains were significantly more prevalent in CD patients than in HC . In contrast, we found a significant correlation of NMS burden in HC with age (r = 0.35) and concomitant diseases (r = 0.36) on a moderate level (p < 0.01).NMS were significantly more common in CD patients compared to HC with pain, insomnia and stigma being the most prevalent symptoms. Mean total NMS score was significantly higher in CD patients  in comparison to HC   as did the CDQ-24 .The DNMSQuest score did not correlate with the TWSTRS I and UDRS but correlated significantly on a moderate to high level with its NMS parts  and CDQ-24 ]. Further, pain assessed by TWSTRS III significantly correlated on a moderate level with emotional well-being  and with BDI . In contrast, there were only few significant correlations on a weak to moderate level of pain domains  with pure motor severity assessed by TWSTRS I and UDRS. In relation to motor severity, most relevant seemed to be the duration of head deviation  and the duration of BoNT effectiveness as a higher duration of head deviation and a shorter time of BoNT effectiveness were associated with more pain.There was a linear correlation of the sensory symptoms domain of the DNMSQuest and the pain domain of the CDQ-24 and TWSTRS. The disability score (TWSTRS II) significantly correlated with pain  and 57% of the variance of HRQoL assessed by EQ-5D VAS could be explained. Major impact on HRQoL had the symptom complexes emotional well-being followed by pain. Stigma and motor severity showed an impact but were not significant in this model.To evaluate the impact of the defined symptom complexes on HRQoL, multiple regression analysis was used with EQ-5D VAS as dependent variable Table . All symIn this multicenter observational case–control study, we describe the non-motor and motor profiles as well as their impact on HRQoL in CD patients in comparison to age- and sex-matched HC using the newly validated DNMSQuest.The majority of investigated CD patients has intermediate motor severity, a combination of different dystonic postures and dystonic head tremor as previously described , mainly in the neck and shoulder area (Comella and Bhatia CD patients were significantly more impaired in their ADLs than HC. Relevant influencing factors on ADL were mainly other NMS like pain, emotional well-being, sleep dysfunction and autonomic symptoms but also motor severity. Van den Dool et al.  showed tNMS have a relevant influence on HRQoL in movement disorders, especially in PD (Martinez-Martin et al. Based on the defined symptom complexes, emotional well-being had the highest impact on HRQoL followed by pain. Emotional well-being was also found relevant for HRQoL in CD patients in other studies (Ben-Shlomo et al. The symptom complex “sleep/fatigue” covers the sleep and fatigue domain of the DNMSQuest even though fatigue is not a sleep-related problem. There are no disease-specific sleep/fatigue scales in dystonia but “sleep/fatigue” are clustered together in other NMS measures, e.g. the Non-Motor Symptom assessment scale for PD (Chaudhuri et al. The symptom complex “cognition” should be evaluated with caution as participants with a history of dementia or evidence of significant cognitive impairment were excluded. Nevertheless, the greater impairment of cognition and attention in CD patients compared to HC, both in subjective and objective evaluation, is an interesting finding, supported by other investigations (Czekoova et al. The effect of BoNT therapy cannot be evaluated as study assessments were performed at the end of a BoNT treatment cycle Table . HoweverThe potential limitations of this study areIn summary, we report that NMS are highly prevalent in CD patients with 95% reporting at least one NMS. Pain, sleep problems, stigma, anxiety and depression being most common NMS. Furthermore, NMS are present throughout the whole course of dystonia and appear independent of age, sex, disease duration, duration of BoNT therapy and socio-economic status. In general, NMS burden and especially emotional well-being and pain have a major impact on HRQoL which may be a greater determinant of QoL compared to the motor symptoms in CD patients. Further, most NMS with the exception of pain, stigma and ADL occurred independent of motor severity of CD. Therefore, in line with previous publications, our data suggests that most NMS could be a primary phenomenon of dystonia. This is of major importance as a diagnostic consideration and for a holistic treatment approach of CD patients. In contrast to the diagnostic criteria for PD including NMS both as supportive and as exclusion criteria (Postuma et al.


Aim of the study. The aim of the study was to evaluate the effect of rehabilitation in the spa and in outpatient clinic on the level of pain and anxiety in patients with degenerative joints and disc disease. Material and methods. The study included a comprehensive treatment conducted in the spa and in outpatient clinic. Observation included 120 persons with disorders of the musculoskeletal system treated in the spa Przerzeczyn-Zdrój. The second group of patients was treated in the rehabilitation clinic. The examinations were performed before and after treatment. The scope of the observations included self-evaluation of anxiety treated as a state and a trait, the level of intensity of pain, medical history, and sociodemographic background interview. In the observations, there were VAS scale and State Trait Anxiety Inventory STAI used.  Osteoarthritis of the musculoskeletal system is accompanied with chronic pain which is the main factor in mood lowering, causing anxiety. Rehabilitation conducted in the framework of spa therapy and outpatient care aims at eliminating or reducing pain and improving physical fitness. Pain relief is an expected phenomenon because it improves the quality of life.  As a result of the spa therapy and therapy performed in an outpatient clinic, there was an improvement in lowering the level of pain and anxiety noted. NCT03405350. 1. Spa therapy and treatment performed in an outpatient clinic reduce the level of pain and anxiety in patients with degenerative disease of the musculoskeletal system. 2. It was found that the therapy conducted in the spa was more effective in lowering the level of pain and anxiety. This trial is registered with  The basic method of spa treatment is balneotherapy. The essence of spa treatment is a complex medical procedure involving the use of physical therapy, psychotherapy, diet, and medication if necessary. The modern spa treatment differs significantly from that used in the recent past. There were medical equipment of the latest generation and modern methods introduced. An integral part of spa treatment is also psychotherapy and health education. Spa therapy is characterized by complexity and diversity which determine the effectiveness of treatment in many chronic diseases . Spa theThe aim of the study was to evaluate the effect of rehabilitation in the spa and in outpatient clinic on the level of pain and anxiety in patients with degenerative joints and disc disease.n = 120 spa patients suffering from pains caused by degenerative joints and disc disease. The age of patients ranged between 29 and 78 years, whereas the average age was 54.8 years. Among the subjects, there were 78 women and 42 men. The study inclusion criterion was the presence of chronic pain resulting from degenerative joints and disc disease or discopathy, the patient's consent to participate in the study, the lack of a history of a past anxiety-depression incident requiring medication, and age below 80 years. The exclusion criteria from the study were lack of chronic pain syndrome, previous anxiety-depression incident requiring medication, and lack of consent to participate in the study. Patients received a series of 10 treatments of different types of therapy depending on the needs and reported problems. A typical set of procedures used in the treatment covered radon-sulfide baths, mud wraps, both group and individual therapeutic gymnastics in the gym and in the pool, laser radiation biostimulation, and interference currents. Any changes concerned only sets treatments from the physiotherapy department. The treatments were performed every second day interchangeably. The number of prescribed, during the stay, individual treatments was 10. The patients used the help of a psychologist and nutritionist and were covered by a health education program, including various forms of relaxation activities such as gymnastics and therapeutic field walks, Nordic-walking, music therapy. Outpatients in group B consisted of patients treated from pain resulting from degenerative joints and disc disease or discopathy. In group B, there were 63 people in the age ranging from 37 to 79 years, whereas the mean age was 55.5 years, 18 men and 45 women. In this group, patients received a series of 10 physiotherapeutical treatments, dry massage, and therapeutic gymnastics. The treatments were performed daily. Patients did not have pool gymnastics, therapeutic baths, therapeutic field walks, psychologist sessions, and health education. They carried out their regular private and professional activities. Group B was subject to the same inclusion and exclusion criteria in the study.The study was conducted in spa Przerzeczyn-Zdroj and Outpatient Rehabilitation Clinic Stabłowice in Wroclaw. The spa observation consisted of patients undergoing complex therapy within the 21-day sanatorium stays. Group A consisted of The scope of the observations included the assessment of pain intensity and self-evaluation of anxiety as a state and as a trait. In the observations, there were two measurement tools used: VAS scale and a standard Self-State and State Trait Anxiety Inventory STAI-C. D Spielberger, J. Strelau, M. Tesarczyk, and K. Wrzesniewski.The STAI questionnaire enables detection of people with significantly low or high levels of anxiety understood as a “constant inner disposition” (trait). It also allows the researcher to record changes in the severity of anxiety assessed as a state that occurs under the influence of certain external stimuli. Anxiety-state is characterized by high volatility; it is a subjective phenomenon, susceptible to the influence of external factors especially threatening factors, and it is associated with the activation of the autonomic nervous system. On the other hand, anxiety as a trait is acquired and very stable, and it makes a person susceptible to excessive anxiety reactions in relation to events and situations which are not endangering. The questionnaire includes a short instruction informing about the nature of the study and its execution method.It consists of two scales: STAI X1 is used to examine the anxiety-state, whereas scale STAI X2 to evaluate anxiety-trait. In each of them, there are 20 statements, and the person being tested should respond to them by ticking the digits from 1 to 4, describing subjective feelings in the most accurate way. To evaluate and calculate the results, there is a key used that does not allow the examiner for a simple summation of numerical values included in the test, and it is necessary to apply another method according to the following principles: 1 = 4, 2 = 3, 3 = 2, 4 = 1. The key contains all the rules of conversion and is available only for the examiner. The first so-called raw results of both scales may be in the range of 20 points (low anxiety) to 80 points (high level of anxiety). The results are mapped to tables with the so-called percentile ranks and sten scores, which in turn are assigned to gender and age. In the study, only raw results were used due to the fact that patients were not divided into groups depending on gender and age. The obtained median value was evaluated in both groups.In the study, there was a standard VAS scale used. The visual-analog scale of pain assessment (VAS) is a graphic and descriptive scale used in the evaluation of pain intensity, where to the level of pain, there is assigned a numerical scale from 0 to 10, 0 denoting no pain, whereas 10 denoting very strong pain. VAS is the most commonly used measurement tool in the assessment of pain intensity.p = or <0.05. Descriptive statistics were conducted. To assess the significance of differences of the obtained results, there were two tests used: the Sign test and Wilcoxon test. The results are presented in tables and in the form of a bar chart.The study was performed in both groups before and after treatment. The results were statistically analyzed with the use of STATISTICA 9.1 program in Polish version. The value received ‘before treatment' and ‘after treatment' for one patient was compared. In the statistical significance, the level was set at The study was approved by the Bioethics Committee of the Medical University in Wroclaw-Opinion No KB-401/2008; there was also written consent of the patients and of the directors of the spa and the outpatient clinic obtained.As a result of the therapy conducted in the spa and in an outpatient clinic, there was improvement in lowering the level of pain and anxiety. Tables Figures 1In the conducted study, the changes in the level of anxiety and pain, under the influence of spa therapy and ambulatory care, were observed. The STAI questionnaire used in the study allows the researchers to record changes in the level of anxiety caused by the influence of other variables, whereas the X-1 scale evaluates anxiety globally. The obtained average raw results' value of both scales showed average level of anxiety in the observed groups. After treatment, there was a noticeable decline in these values; thus, the change was in the direction of reducing the level of anxiety, and it was also noted in case of VAS that the level of pain declined. The group treated at the spa obtained a better result. This difference may be the result of a comprehensive treatment provided in the spa including psychotherapy, relaxation, and educational activities.Pain, especially chronic pain, as physical and psychological stressor, affects the disposition and mood and lowered mood and affects the perception of pain intensity. Thus, the emergence of chronic illness can be considered as a traumatic factor for the patient. Chronic diseases are potent stressors not only because of the excessive length of their duration but also of the intensity of therapy and the accompanying sensations of pain arising from the diagnostic, therapeutic procedures, and the essence of the disease itself.The ability to recognize and deal with the experiences associated with the disease, especially negative emotions, seems to be a major effort in overcoming the disease . IllnessBoth chronic pain and the accompanying anxiety, lowered mood, or depression are the onerous and debilitating ailment in the population. Coexistence of these symptoms limits functional state and primarily impairs the physical, mental, and social development –10. DiffResearch carried out by Lelonek and Cieslik confirmed the dependence of the level of anxiety and disease duration. This factor may predispose to increased anxiety-state and anxiety-state, and the longer the duration of the disease, the higher the level of anxiety as a state and a trait . It is iAt the same time, it is crucial to emphasize the diagnostic difficulties of atypical depression and appearance of “masking” of the depression process in the form of chronic feeling of pain which complicates diagnosis and therapy –18.Research by Talarowski-Bogusz et al. conducted in patients with osteoarthritis of the spine and hips have shown that the use of physical treatments such as low magnetic field and biostimulating laser causes a reduction of pain in patients with anxiety, depression, and lowered mood. Moreover, in these patients, the reduction of the intensity of pain sensations alleviates the intensity of the symptoms of depression and anxiety only in case of mild-to-moderate severity .Given the mutual dependence of pain, anxiety, and lowered mood and involvement of the particular structures of the brain and neurotransmitters in the appearance of these conditions, it appears necessary to implement a complex therapy both in terms of medication, psychotherapy, and other techniques. It also seems that a spa therapy has a lot to offer, being a response to dehumanized modern medicine. Currently, there is a huge need for a holistic recognition of a man, his state of health, and disease. Conditions in the spa can be a curative factor in itself in terms of infrastructure and the selection of competent and sympathetic staff. Spa treatments meet the criteria for a holistic model of therapy. Regardless of the methods recommended in the spa, patients treated there have time to rest and cultivate relationships with people, nature, beautiful landscape, and pull away from the home or work environment to change health habits especially in terms of diet, physical activity, and the fight against addictions and pain –23.Spa therapy and treatment performed in an outpatient clinic reduce the level of pain and anxiety in patients with degenerative disease of the musculoskeletal systemGreater efficacy in reducing pain and anxiety was found in patients treated at the spa