Our aim was to determine characteristics of children with chronic critical illness (CCI) admitted to the pediatric intensive care unit (PICU) of a tertiary care children’s hospital in Turkey. The current study was a multicenter retrospective cohort study that was done from 2014 to 2017. It involved three university hospitals PICUs in which multiple criteria were set to identify pediatric CCIs. Pediatric patients staying in the ICU for at least 14 days and having at least one additional criterion, including prolonged mechanical ventilation, tracheostomy, sepsis, severe wound (burn) or trauma, encephalopathy, traumatic brain injury, status epilepticus, being postoperative, and neuromuscular disease, was accepted as CCI. In order to identify the newborn as a chronic critical patient, a stay in the intensive care unit for at least 30 days in addition to prematurity was required. Eight hundred eighty seven (11.14%) of the patients who were admitted to the PICU met the definition of CCI and 775 of them (87.3%) were discharged to their home. Of CCI patients, 289 (32.6%) were premature and 678 (76.4%) had prolonged mechanical ventilation. The total cost values for 2017 were statistically higher than the other years. As the length of ICU stay increased, the costs also increased. Interestingly, high incidence rates were observed for PCCI in our hospitals and these patients occupied 38.01% of the intensive care bed capacity. In conclusion, we observed that prematurity and prolonged mechanical ventilation increase the length of ICU stay, which also increased the costs. More work is needed to better understand PCCI. Many critically ill patients survive their first acute attacks, but they continue to live with a syndrome that requires long-term intensive care, known as chronic critical illness (CCI) . Adult CIn childhood, CCI occurs in children with prolonged length of stay (LOS), technology addiction, or multiple organ system involvement; the prevalence of CCI is increasing . TechnolAlthough PCCI has been discussed extensively worldwide, it has not been studied in Turkey. The aim of this study is to determine characteristics and clinical results of PCCI in the three separate PICU and neonatal ICU (NICU).This multicenter retrospective study was conducted in the NICU and PICU of Van Yuzuncu Yıl, Kahramanmaras Sutcu Imam, and Sakarya Universities in Turkey between 1 November 2017 and 31 October 2018, with the Non-interventional Clinical Research Ethics Committee Approved number of 21.09.2017 / 10. Ethics committee waived patient informed consent on the study. Sakarya University has 33 NICU and 8 PICU beds out of a total bed number of 970 and pediatric clinic bed number of 72, respectively. Kahramanmaras Sutcu Imam University has 30 NICU and 10 PICU beds out of a total bed number of 600 and pediatric clinic bed number of 55. Van Yuzuncu Yıl University has 45 NICU and 15 PICU beds out of a total bed number of 662 and pediatric clinic bed number of 32, respectively.NCT0330851.In this study, medical records of pediatric patients from birth to 17 years of age in the NICU and PICU between January 2014 and December 2017 were examined. The patients were divided into two groups as neonatal between 0–28 days and pediatric patients between 28 days and 17 years. The pediatric group was then divided into two subgroups, infant (1–11 months) and pediatric (1–17 years). Separate criteria were set to identify neonatal and pediatric CCIs. Pediatric patients staying at the ICU for at least 14 days and having at least one additional criterion were accepted as CCI  [The demographic characteristics of the patients, primary admission diagnoses, and clinical outcomes were evaluated according to the definition of CCI using standard statistics. To calculate the cost in US dollars, the average annual exchange rate between the US dollar and Turkish Lira (TL) was applied based on data obtained from the Central Bank of the Republic of Turkey .The data were evaluated using the IBM SPSS Statistics Standard Concurrent User V 25  statistical package program. Descriptive statistics are given as number of units (n), percentage (%), mean, standard deviation, median, first and third quartiles, and minimum and maximum values. Risk factors that are thought to have an effect on mortality were evaluated with the univariate and multivariate Cox proportional hazard model. Backward Wald elimination method was used to create the final model in multivariate analysis. Hazard rate values are given with 95% confidence intervals. For Cox regression analysis, p <0.10 was considered statistically significant.Out of 7961 PICU admissions during the study period, a total of 887 (11.14%) met the consensus definition for CCI. The reasons for hospitalization of these patients are shown in In Factors affecting mortality, with and without correction, are given in In In the intensive care units in developed countries, although most critically ill adults recover, 5–10% of them go from acute critical illness to permanent, and, in some cases, to CCI , 10. PerFor this, a standard definition of CCI should be made. Various definitions for CCI include ICU stay time, prolonged mechanical ventilation, or tracheostomy. The use of a uniform definition for adult CCI is mandatory both to strengthen medical information about these patients and to guide health policy , 13. AccIn most of the studies, CCI was defined as only a chronic condition that would require a stay in ICU for more than 28 days –19. NineIn our study, 11.14% of the patients who applied to the PICU met the definition for CCI. Ishihara et al  determinUnderstanding the characteristics of LOS patients in the PICU will make it easier for PICU healthcare providers to plan for critical care services . A smallIn a meta-analysis, it was reported that the rate of adult CCI discharge to home varies between 20.2% and 21.8% . NamachiOur study has some limitations. The sampling technique is not random but rather is based on manual chart review and referrals from other healthcare providers through interpersonal relationships. Since there is no common identification code for PCCI, data may not be complete, as some patients’ diagnoses of PCCI may have been missed. Another limitation is that this study does not include readmissions rates after discharge. One of the important limitations of the study is lack of a single nationwide database. Thus, this study does not contain data from public hospitals, private hospitals, and other university hospitals. Therefore, our findings will need to be confirmed by larger case studies.In conclusion, early detection of NICU and PICU patients who may turn into CCI can help target interventions and resources for both patients and families. This is the first study conducted in Turkey on this issue. For this reason, we have determined some criteria for CCI in this study. According to the criteria, high incidence rates were observed for PCCI in our hospitals. CCI patients occupied 38.01% of the intensive care bed capacity. Moreover, we observed that prematurity and prolonged mechanical ventilation increase the length of ICU stay, which increases costs. More work is needed to define PCCI more clearly.S1 Data(XLSX)Click here for additional data file.S1 Table(DOCX)Click here for additional data file.


Objective: The most common indications for spinal surgery are low back pain and associated disabilities caused by disc herniation. Given the high prevalence of low back pain, the critical nature of pain assessment in these patients, and knowledge about the influencing and predisposing factors, we sought to evaluate the clinical and radiologic findings associated with pain relief and postoperative recovery in patients who underwent bilateral lumbar discectomy.Methods: From March 2016 to October 2020, a prospective cohort study was conducted. This study included adult patients with symptomatic disc herniation in the L4-L5 and L5-S1 segments who were candidates for bilateral discectomy. Before and after surgery, patients were evaluated for lumbar and radicular pain and the Oswestry Disability Index (ODI) score and at the four, 12, and 24-week follow-up. Meanwhile, a variety of demographic, clinical, and radiologic factors was collected and statistically analyzed.Results: This study enrolled 30 patients. The average age of the patients was 41.2 years, with 22 males and eight females. Twelve of these patients had disc involvement in the L4-L5 region, while 18 had disc involvement in the L5-S1 region. Statistical analysis revealed that radicular pain and disability associated with low back pain significantly decreased following surgery (P=0.001). However, there was no significant reduction in back pain (P>0.05). Patients with a higher body mass index (BMI) and neurological claudication had a lower reduction in radicular pain (P<0.05). Moreover, a higher BMI and the presence of instability pain are associated with an increased likelihood of postoperative lumbar pain relief (P<0.01). Among the radiological variables, increased disc height was associated with a more rapid recovery from low back disability (P=0.003). Furthermore, a larger diameter of paraspinal muscles at the level of the herniated disc was associated with a more rapid improvement of lower back pain (P=0.021).Conclusion: The use of discectomy in patients with lumbar disc herniation significantly alleviates postoperative and follow-up radicular pain. Age, BMI, neurological claudication, instability pain, and paraspinal muscle diameter played a role in postoperative pain relief. Increased disc height was associated with a more rapid decline in the ODI score. Future studies with larger sample sizes are recommended. Intervertebral disc herniation refers to the displacement of disc material beyond its normal limits . ProtrusLower back pain is a frequent complaint in outpatient orthopedic clinics and is the leading cause of activity limitation in people under 45. Around 80% of people will experience lower back pain at some point in their lives . DespiteL4-L5 and L5-S1 discs are the most frequently affected , it is lIn most cases of disc herniation, rest, analgesics, and physical therapy help alleviate pain. Other options for symptom relief include transforaminal or epidural corticosteroid injections. If the pain persists for more than four to six weeks or worsens despite treatment, the surgeon may consider surgical intervention if neurologic deficit and refractory pain develop . DiscectMicrodiscectomy has established itself as the gold standard in disc herniation surgery, even though some surgeons occasionally continue to perform a standard open discectomy. Kovacevic et al. found that both procedures had a favorable overall functional outcome. The advantage of microdiscectomy was a greater reduction in leg pain and a lower reoperation rate . Incomplete pain relief following surgical treatment of lumbar disc disease is a daily challenge for neurosurgeons. The patients in this study were those for whom less invasive procedures were not be considered effective; therefore, we tried to predict the prognosis of the treatment in relieving pain preoperatively by clinical and imaging findings. The purpose of this study was to examine the characteristics of patients with lumbar disc herniation, their imaging findings, and their overall outcome following bilateral discectomy surgery over six months. Furthermore, we examined whether the MRI findings were associated with disease characteristics and overall surgical outcomes.This prospective cohort study was conducted on patients admitted to Rasoul Akram Hospital's neurosurgery department with lumbar disc disease, scheduled for elective bilateral discectomy surgery between April 2016 and April 2020. All operations were performed using a single technique and by a single neurosurgeon. The Iran University of Medical Sciences ethics committee approved all phases of this study. In this study, we used purposive sampling from among non-probability sampling methods.Our study included all patients who met the following criteria: (1) Subjects who are over the age of 18 years; (2) Herniation (extrusion) of the lumbar discs at the L4-L5 and L5-S1 levels ; (3) Patients scheduled to undergo bilateral discectomy; and (4) Patients who were not suitable for less invasive procedures due to the severity of disc herniation or neurological deficits. Patients with a history of skeletal or spinal abnormalities, prior lumbar disc prolapse surgery, or an inability to comply with follow-up were excluded.For each patient, we evaluated the demographics , as well as clinical , and radiological data . To our knowledge, this is the first study to evaluate the paraspinal muscles area as a variable in patients who underwent lower lumbar discectomy. For the measurement of the paraspinal muscles area, we evaluated the lumbar MRI images in the transverse plane at the level of the involved disc, using MARCO PACS diVision software .Patients were evaluated using MRI imaging methods. Baseline MRI studies of the lumbar spine were performed using a single device operating at 1.5 T, using a standard protocol turbo spin echo (TSE) or fast spin echo (FSE) sequences with sagittal and axial T1 and T2 weighted images . The preVisual analysis of all MRI findings was performed in consensus by an experienced radiologist unaware of the patients' clinical data. Additionally, a detailed profile of patients' clinical characteristics was compiled, including their admitted demographics and clinical characteristics. During surgery, a coronal hemilaminectomy was performed on the involved segment. The herniated disc material was removed following Flavectomy, and loose disk fragments were evacuated bilaterally from the disk space using gentle medial retraction of the affected nerve roots.The Oswestry Disability Index (ODI) questionnaire was used to assess functional outcomes. The primary outcome measure is the ODI score at preoperative and various follow-up visits. The study participants completed this questionnaire before surgery and four, twelve, and twenty-four weeks afterward. Moreover, patients were asked to complete a questionnaire regarding their low back and radicular pain using a visual analog scale (VAS) score concurrently with the ODI questionnaire . No findStatistical analysisFor descriptive analysis, the mean and standard deviation were used to describe continuous variables, while the number and regarded frequency were used to analyze categorical variables. The changes in ODI score, radicular pain, and low back pain preoperatively and at various follow-ups were analyzed using repeated measure analysis of variance (ANOVA). Additionally, multivariate linear regression was used to determine the factors associated with improving the ODI score, radicular pain, and preoperative low back pain following surgery. Statistical significance was defined as a P-value less than 0.05, and all statistical analyses were conducted using IBM SPSS Statistics for Windows, Version 22.0 . We used G*Power software to determine the sample size. The sample size calculation was conducted based on a study conducted by Li et al. .For the final analysis, data from 30 patients were retrieved. The mean age of the participants was 41.2±12.6 years. The study population consisted of 22 (73.3%) males and eight (26.7%) females. The mean BMI was 25.6±2.8 (range 22-31) and 16 patients (53.3%) were overweighted or obese. Lower back pain was reported to have lasted an average of 6.8 months (ranging between one to 48 months). Among the participants, 12 (40%) and 18 (60%) had a disc herniation at the L4-L5 and L5-S1 levels, respectively. Table Of the 30 patients, 18 (60%) had neurological claudication and seven (23.3%) complained of instability pain. MRI evaluation revealed that seven patients (23.3%) had no visible endplate signal changes, five patients (16.7%) had grade I Modic changes, 13 patients (43.3%) had grade II Modic changes, and five patients (16.7%) had grade III Modic changes. Four patients (13.3%) were grade III, 14 patients (46.7%) were grade IV, and 12 patients (40%) were grade V, according to the Pfirrmann grading system for lumbar disc degeneration.Table Table In non-radiologic variables, higher BMI  and instability pain  were associated with improvement in postoperative low back pain. Meanwhile, an increase in the diameter of paraspinal muscles at the level of the damaged disc was associated with a faster postoperative recovery of low back pain . When the same analysis was performed on the ODI score, it was discovered that higher disc height was associated with a more significant decline in the ODI score following surgery .We compared the ODI questionnaire and VAS scores of patients undergoing bilateral discectomy for low back and radicular pain preoperatively and during the 4th, 12th, and 24th week postoperatively against MRI findings in this study. The ODI is widely regarded as the gold standard for low back functional outcome measures .The results indicate that patients who undergo discectomy surgery experience a significant reduction in radicular pain (P =0.001). Furthermore, disability due to low back pain decreased significantly in these patients, following surgery and at the fourth, 12th, and 24th-week follow-up (P =0.001). There was a significant correlation between younger age, lower BMI, the absence of neurological lameness, and a more rapid recovery from radicular pain following surgery. This finding is supported by the fact that being overweight and obesity can impede the process of recovery. As we can see in a study conducted by Rihn et al., obese patients benefited less from lumbar disc herniation surgery and conservative treatment . AdditioDue to the aging population in developing countries and physically demanding work, lumbar disc herniation has become the most common reason for spine surgery . ParesthIt is discovered that instability pain is associated with greater improvement in back pain in these patients. This concern may be justified in light of the significant impact discectomy surgery has on pain relief in individuals who have suffered from mechanical pain.Our findings indicated no correlation between MRI findings and low back or radicular pain; however, there was a correlation between ODI and MRI disc height. As a result, patients with a higher disc height had better surgical outcomes. Budiono et al. recently described this finding, indicating that higher disc height is a prognostic factor in patients suffering from L5-S1 degenerative disc disease .Heo et al. evaluated 11 patients with bilateral lumbar disc herniation of the L4-L5 or L5-S1 segments who underwent surgery using a percutaneous biportal endoscopic approach. After one week, the mean VAS scores for the back and both legs had decreased significantly (P< 0.05), as had the mean preoperative Oswestry disability scale score (P< 0.05) . These fAljanabi et al. evaluated the short-term clinical outcomes of open limited discectomy for lumbar disc prolapse in 42 patients using the Japanese Orthopedic Association Score (JOAS) and MacNab criteria, demonstrating that both scores improved significantly (P<0.001), highlighting the efficacy of this method . These fLi et al. described the technical details of unilateral percutaneous transforaminal endoscopic lumbar discectomy (PTELD) and compared unilateral versus bilateral PTELD for L3/4 or L4/5 lumbar disc herniation with bilateral symptoms in a randomized clinical trial .According to the MacNab standard, their findings indicated that both groups experienced a significant postoperative improvement in VAS and ODI scores and similar clinical outcomes. However, the VAS score for back pain one day after surgery was significantly lower in the Unilateral-Approach group than in the Bilateral-Approach group (P<0.05). Although the results agree with ours, this study divided the patients into two groups, which was not done in our study.Based on our findings, the association between patients' radiologic findings and radicular pain improvement is insignificant, implying that Modic and Pfirrmann changes do not affect patient improvement. Prior research has produced conflicting findings on the subject. While it has been reported that patients with Modic grade I change to experience the same level of pain relief as those without Modic changes, several studies indicate that patients with Modic or Pfirrmann changes may experience more residual pain or have a greater risk of recurrent disc herniation -25.Several studies supporting the latter assertion are retrospective, making consensus difficult and evoking the need for a comprehensive prospective investigation.We recognize that including only patients who underwent a single surgical technique may constrain the range of findings. Larger sample sizes as well as longer follow-up periods could be used in future studies.The use of discectomy in patients with lumbar disc herniation L4-L5 or L5-S1 significantly alleviates postoperative and follow-up low back and radicular pain. Age, BMI, neurological claudication, instability pain, and paraspinal muscle diameter played a role in postoperative pain relief. Increased disc height was associated with a more rapid decline in the ODI score. Subsequent studies with larger sample sizes as well as longer follow-up are recommended to determine the effect of other radiological findings on predicting patient improvement.


A patients' main concern when visiting the dentist is the pain experience during the procedure and postoperatively. Patients who are undergoing dental surgical procedures in particular may experience more concerns and higher level of anxiety and stress that can affect their psychology and decision-making ability. A thorough discussion with the patients about the planned surgical procedure and the expected postsurgical pain and discomfort level is crucial to reduce their fear and stress. Despite increasing popularity of dental implants, limited data are available on pain experience related to surgical implant placement. This review is to discuss and compare postoperative pain and discomfort level after dental implant placement procedure and tooth extraction. The review has a clinical significance as it can be used as a reference when explaining to the patients about the anticipated pain and discomfort level after implant placement.  Informing patients about implant placement surgical procedure and the anticipated postsurgical pain can reduce their anxiety level and affect postsurgical pain and discomfort. Implant placement surgical procedure is less unpleasant than tooth extraction, with less postsurgical pain and limitation of daily activities. Fear of dental treatment has been ranked as the 4th most common fear among the population . The mosTo manage and control patients' fear and anxiety before a planned dental surgical procedure, a thorough discussion should be attempted. Providing information to patients can help dentally anxious individuals prepare for treatment and subsequently reduce anxiety levels .As dental implants acquired much popularity as a first treatment option chosen by the patients, limited information is available on the pain experience associated with the surgical placement of dental implants . CompariPatients tend to overestimate the fear of pain of the dental treatment that they have not experienced, compared to those they have experienced in the past . Most ofOn the other hand, the majority of these candidates may have an experience of at least one tooth extraction. Comparing the two surgical experiences will help the patients to relate the anticipated pain after implant surgery which can influence their decision-making on proceeding with the treatment providing clear and accurate information about expected pain during treatment which will result in more reliable communication between clinicians and patients. This will enable patients to have a more realistic expectation of the treatment process and reveal all risks that might influence or conflict with their decisions .Well-informed patients about their procedures seem to be less anxious and more comfortable .A qualitative study of patients' views of techniques to reduce dental anxiety was conducted by Wang et al. . Four faDental anxiety has been reported as having direct influence on pain perception in dental procedures in different laboratory and clinical studies. It is closely linked to painful stimulus and increased pain perception. Therefore anxious patients may experience more pain that lasts longer with exaggerated memory of pain .There is a positive relation between the patient's fear and anxiety level and pain perception after dental procedures. Croog et al.  assessedThere are limited data comparing the pain experience of dental extraction with dental implant surgery on the same patient. This can be advantageous as the pain experience reported by the same subject will be more consistent and the comparison will be more reliable.One study that compared the pain experience in patients who went through both tooth removal and dental implant surgery was carried out by Tabrizi et al. . They coThis finding is in line with a conclusion of a study conducted by Abolfazil et al. . The stuPain and inflammation following the placement of dental implants were assessed by González-Santana et al. . They stAl-Khabbaz et al.  assessedPain experience and anxiety following dental implant placement was investigated by Hashem et al.  using quA comparison study conducted by Yao et al.  revealedThe patients' perspective, i.e., how patients perceive their oral health, is being recognized recently as a significant outcome in modern implant dentistry. A study was conducted to assess how patients perceive the perisurgical stages of implant placement and whether the overall perceived burden of the surgical process is related to specific stage of treatment and to compare patients' perceptions during implant placement with tooth extraction. Considering treatment stages, burdens were highest for anesthesia and lowest for side effects. The study results demonstrated that even though implant placement requires basically similar surgical procedure and instruments for incision, mucoperiosteal flap reflection, bone drilling, and suturing, patients seem to perceive the procedures related to bone and soft tissue less burdensome than during surgical tooth extraction. It can be concluded that implant placement was rated as least burdensome, especially in relation to bone and soft tissue manipulations such as pressure during incision or vibration due to drills compared with surgical tooth extraction .Many factors are associated with the reported pain intensity in relation to the implant placement procedure such as operator experience, female gender, and surgical difficulty as reported by Al-Khabbaz et al. .The surgeon's experience plays a role in reducing the perisurgical and postsurgical pain . Morin eA number of implants placed and the related regenerative procedures  are associated with increased postsurgical pain and swelling. Moreover, pain experience is more intense in older patients and smokers , 13.It is proven that the longer the duration of the procedure, the more swelling, pain and discomfort perceived by patients .Location of the placed implant and the proximity to vital structures is correlated with pain perception. Swelling is greater in patients with implants placed in the posterior versus anterior zone and in free end spaced or totally edentulous patients versus interdental spaces.González-Santana et al. , who stuMoreover, a significant association was observed between swelling and more number of implants placed and with surgery involving sinus lift or bone regeneration procedures . The resLocation of the placed implant and the proximity to vital structures is correlated with pain perception. Swelling was reported to be greater in patients with implants placed in the posterior versus anterior zone and in free end spaced or totally edentulous patients versus interdental spaces .Timing of implant placement and loading are also related to the pain experience. Immediate implants may be associated with more discomfort as patients' undergo an extensive surgical procedure of both tooth extraction and implant placement. Urban and Wenzel reported that patients experienced low to moderate pain with severe swelling after immediate implant placement in the molar area with the regenerative procedure . ImmediaIn terms of flap design, flapless procedure has less pain intensity and duration and faster healing time than open flap procedures. There is a relatively high probability (43%) of experiencing no pain with no medications, and this probability could be increased by taking steroidal anti-inflammatory agents . Khouly Minimally invasive procedures are always preferred to reduce patients' anxiety and the pain experience and hence increase the treatment acceptance rate by the patient.It is suggested that pain intensity is higher with tooth extraction compared to the implant placement procedure. This can be explained as most of the extracted teeth are usually chronically inflamed or symptomatic. There is a significant relation between pre-extraction tooth status and the pain intensity perceived after extraction, as postextraction pain can increase 3 folds in patients with symptomatic teeth , 23. TheAnother explanation is that dental implant surgery is a more controllable and less traumatic procedure than tooth extraction. Subsequently, less pain and discomfort is expected postsurgically.More research studies should be carried out to compare between surgical implant placement and other oral surgical procedures on the same individuals with larger sample sizes, taking into consideration the contributing factors that might affect the pain perception by implant candidates.Informing patients about the anticipated surgical procedure of implant placement and the postsurgical pain intensity can reduce their anxiety level and subsequent postsurgical pain and discomfort. Patients can be informed that, in general, implant placement surgical experience is less unpleasant compared to tooth extraction with less postsurgical pain and limitation of daily activities. However, some factors can increase the pain intensity and discomfort level on individual bases.


The SP test confirmed muscle-referred pain for (i) all GS patients with 90.6% positive thermograms ) and (ii) those sciatica (n = 8) patients who reported pain sensation during the test with 20.6% positive thermograms ). The remaining sciatica (n = 22) patients did not report pain during the test and presented a Δ₸° decrease and the AURP size below 1%. Conclusion: Amplified vasodilatation suggesting nociplastic pain involvement was confirmed for all GS and sciatica patients who reported painful sensations in the zone typical for gluteus minimus referred pain during the test. Gluteal syndrome (GS) mimicking sciatica is a new disease that has been recently recognized and included in the International Classification of Diseases, 11th Revision. The present study examines nociplastic pain involvement in GS and sciatica patients using a new Skorupska protocol (SP) test that provokes amplified vasodilatation in the area of expected muscle-referred pain. A positive test is confirmed if there is (i) a development of autonomic referred pain (AURP) and (ii) an increase in the delta of average temperature (Δ₸°) > 0.3 °C at the end of the stimulation and during the observation SP phases. Chronic GS ( The newest data indicate that low back pain (LBP) is characterized by different types of pain, including nociceptive pain, neuropathic (radicular) pain that travels down the legs, and—in some cases—nociplastic pain, which is caused by the amplification of pain in the central nervous system. It has been noted that these pain subtypes can overlap. For example, a patient may present with sciatica and diffuse symptoms outside of the usual pathoanatomical referral patterns ,2. A newThis study examines the involvement of nociplastic pain in GS and sciatica patients based on the presence of amplified vasodilatation reflecting muscle-referred pain.This study was approved by the Ethics Committee of the Poznan University of Medical Sciences (number 689/20) and was conducted in accordance with the Declaration of Helsinki. Before data collection, all subjects gave written informed consent to participate in the study. A detailed description of all of the examinations and treatment procedures, including muscle noxious stimulation as well as the risks involved in the study, was provided to the participants. The participants had the right to refuse the SP test and withdraw from the study at any time without penalty.Gluteal syndrome (GS) is a subtype of chronic low-back leg pain that mimics sciatica. GS is defined as aching myofascial pain arising from trigger points located in one of the three gluteal muscles. The GS diagnostic criteria are as follows: (i) sign pressure on the trigger point that is responsible for the pain occurrence and that reproduces the referred pain pattern; for gluteus minimus—the pain pattern is similar to that of sciatica, whereas for the gluteus medius and gluteus maximus—pain is referred to the buttock and rarely to the thigh; (ii) straight-leg raising is usually restricted because of the tightness in the hamstring and gluteus maximus muscles. GS is classified as nociplastic pain that is related to the central sensitization process (nociplastic pain) and that is based on the presence of primary hyperalgesia (trigger points presence) and secondary hyperalgesia (muscle-referred pain). The SP test confirms nociplastic pain if a patient with trigger points presents test-provoked vasodilatation and/or vasoconstriction that is dependent on the tested muscle in the muscle-referred zone ). The validation study confirmed that a positive SP test resulted in the autonomic phenomenon for trigger points exclusively. The localization of the autonomic phenomenon was coincident with both the pain sensation reported by the patients during the test and their daily complaint area. TrPs-negative pain patients and healthy subjects did not present any autonomic phenomenon ), and they reported no pain sensation during the test. For gluteus minimus trigger points, the thigh was confirmed as the diagnostic area of the SP test .A secondary analysis of the thermal data extracted from previously published studies was performed to determine the differential diagnosis of the GS and sciatica subjects based on the SP test ,21,22. SThe current study includes 95% unpublished thermal data. Our previous studies presented 3 representative thermograms out of 320 thermograms recorded during the 16 min procedure.n = 35) of them were excluded: eighteen (n = 18) for not meeting the inclusion criteria and seventeen (n = 17) declined to participate. All of the participants finished the diagnostic protocol. The examined patients presented variable leg-pain zones ; only the thigh zone was painful for every participant (Eighty-five patients were assessed for eligibility. Thirty-five (ticipant . The incn = 20) or chronic sciatica (n = 30) was diagnosed by an experienced neurologist and a myofascial pain specialist with over 10 years of experience. Then, each of the participants was assessed using the SP test (detailed test description below). Gluteal syndrome was confirmed if a patient presented a minimum of two active trigger points within the gluteus minimus muscle according to Travell and Simons’ diagnostic criteria—i.e., a taut band, spot tenderness, pain recognition, and a limited range of movement. Moreover, following the newest recommendations, we considered additional diagnostic criteria, such as the reproduction of the lower leg symptoms experienced by the patient and that were recognized as familiar, the rarely accessible taut band criterion, and spontaneous referred pain [n = 30) of radicular origin was based on a clinical bedside examination accompanied by a positive straight leg raise test and MRI results. Every patient classified as having gluteal syndrome . The second one is an increase in the delta of the average temperature (Δ₸°) in the examined body part of more than 0.3 °C. Both diagnostic parameters were demanded to classify the test results as positive (SP(+)).A positive test was confirmed if a patient with trigger points presented test-provoked vasodilatation and/or vasoconstriction in the daily complaint area that was coincident with the region of the referred pain pattern of the tested muscle. The autonomic phenomenon is defined by two parameters. The first parameter is the percentage size of the vasomotor reactivity subarea with a temperature that is not registered for the patient before the stimulation (T0), which was named autonomic referred pain (AURPT0 explanation: Detailed AURPT0) reflects the size of the phenomenon revealing the temperature that was not registered for the patient before the stimulation. Technically, AURPT0 is an isolated region (segmented part of the thermogram) with a defined temperature range that is individually measured in the ROI for every 3 s of the procedure for every case. Originally, the AURPT0 size (cm2) was calculated manually by a technician, and then the percentage size of the area within the thigh, calf, and foot was calculated separately. That method allowed the size of the AURP to be calculated at the end of both test phases. Currently, the new codes created for the purposes of the test in the MATLAB environment allowed an automated AURP size calculation for each of the 320 recorded thermograms [Autonomic referred pain Trigger point examination based on the palpatory diagnostic criteria according to Travell and Simons . (2)Thermal side-to-side comparison of the patients at rest to exclude a possible neuropathic pain component (confirmed there was a temperature decrease of more than 0.5 °C if in the pain subarea compared to the opposite side).(3)Examination towards the autonomic response of the trigger points at the daily complaint area that is coincident with the referred pain zone for the examined muscle.(4)Numerical analysis of the thermograms.Short description of the exploration:The examination consisted of two parts: (i) noxious, nociceptive muscle stimulation under thermal camera control of the area with expected muscle-referred pain (10 min) and (ii) the post-stimulation resting phase—further thermal observation of patients at rest (6 min). For part (i), the noxious stimulation of the two most sensitive trigger points (GS) or the most tender muscle areas (sciatica) within the gluteus minimus muscle was applied using the continuous fast-in-fast-out dry needling technique. During the whole noxious stimulation, the patients reported the localization of the pain sensation provoked by needling .T0 size and Δ₸° of the thigh region were calculated. The significance of both diagnostic parameters was checked for each of the 320 thermograms.Numerical analysis of the thermograms: A comparative analysis of the thermograms (320) was registered every 3 s, and the thermogram recorded for the patient before the stimulation was performed using MATLAB. For every thermogram, the thigh subarea was segmented. Then, both the AURPAn illustration of the SP test and an example of the test results are shown in n = 19. The total sample size for this publication was n = 50.The sample size for this publication was limited due to the patient availability for each group. Therefore, non-parametric tests were performed instead of ANOVA. For an exact test at a significance level of 0.05 with a beta power of 0.95, the lowest possible sample size is n = 20) and sciatica (n = 30) patients depending on the noxious stimulation sensitivity reported during the SP test. The tests were applied to compare the data for AURP and Δ₸° between the aforementioned groups. To obtain the significance of the p values, a post hoc Dunn test was performed. Due to the multiple comparison problem, the aforementioned test was corrected using the Holm–Sidak procedure. The Dunn test was prepared using the dunn.test package in R. Values, figures, and tables in the text are expressed as the means ± standard deviation (SD) or as quartiles with the median. The significance level was set for all tests are at p  <  0.05. Statistical analysis was performed using IBM SPSS Statistics version 26 and MATLAB version R2021. Firth’s Regression was prepared in R version 4.0.5 using the logistf package .Exact two-tailed Mann–Whitney U tests with corrected ties were performed to assess the differences between gluteal syndrome (p < 0.05). The AURPT0 and Δ₸° trends over time and the significant differences for both (*) parameters together, which were measured every 3 s, are shown in The SP test confirmed muscle-referred pain based on the presence of amplified vasodilatation among the gluteal syndrome and sciatica patients who reported pain provocation in the symptomatic region (SP(+)). Both groups presented amplified vasodilatation in the expected diagnostic zone (thigh ROIs), which differentiated them significantly from the sciatica patients who did not present any positive response to the test (SP(−)) , with a bigger AURPT0 size compared to the GS patients  sciatica subjects (T0 for the GS and SP(+) chronic sciatica patients was smaller compared to previously published data of subacute and chronic sciatica patients with the co-existence of TrPs [p < 0.005). The GS patients presented a smaller AURPsubjects . Further of TrPs ,21,22. TRecently, it has been reported that the stimulus intensity, rather than the pain severity or clinical state, determines how strongly the autonomic nervous system (ANS) responds to noxious stimulation in the pain region . Based oIt is likely that the amplified vasodilatation that was observed occurred due to the activation of the non-noradrenergic vasodilator system, which affected the processes of reflex cutaneous vasoconstriction and vasodilatation ,32 and rThe hypothesis of why the autonomic phenomenon was confirmed for some of the sciatica patients who did not present trigger points relates to the fact that chronic pain is characterized by dynamic interactions between sensory and contextual processes in the brain , which are mediated by feed-forward and feedback processes . Some ofIf this hypothesis is correct, the SP test will allow us to visibly distinguish between patients with positive referred pain and those with negative low-back leg pain. It is true that chronic pain may lead to the hyperarousal of the sympathetic nervous system . HoweverLimitations of this study:The present study only considered SLR-positive gluteal syndrome patients. Future studies considering all GS patients are necessary. Furthermore, a larger group of subjects is necessary to observe calf and foot responses to the SP test. To improve the quality of the study, a control group should be considered. Moreover, the therapist who performed the dry needling in the present study was not blinded to the trigger-point diagnosis, which could have biased the results to some extent.Consequences for knowledge and future research:The main point of interest in the nociplastic pain field is to find an objective way to diagnose pain. It seems that the SP test could serve as a valuable tool for diagnosing central sensitization subtypes that are related to trigger points. Additionally, the SP test is interesting for modern medical thermography that is focused on developing strict diagnostic protocols that are typical for active dynamic thermography, as this type of thermography can better reveal pathological processes thanks to its high-contrast pictures. The advantages of the SP test include a detailed analysis of the segmented parts of the thermograms and the need to confirm significant results for both diagnostic parameters. Moreover, the fact that the SP test results were supported by MATLAB indicates that this technique meets the highest standards in medical thermography. Future studies should explore the application of the SP test together with quantitative sensory testing of other muscles with trigger points.Summary: Amplified vasodilatation suggesting nociplastic pain involvement was confirmed for all GS and sciatica patients who reported pain sensations in the zone typical for gluteus minimus referred pain during the SP test. The GS patients presented less intense but longer-lasting amplified vasodilatation in the pain region compared to SP-reactive sciatica subjects. It is not clear whether the SP-reactive sciatica patients were overlooked during the pressure palpation that was performed to confirm an overlapping GS diagnosis or if those patients presented with other subtypes of nociplastic pain.


To explore the effects of modified Wenjing decoction combined with online publicity and education on the treatment of primary dysmenorrhea of cold coagulation and blood stasis. n = 59) and control group (n = 52). The control group received online publicity and education and conventional treatment, and the treatment group received online publicity and education and modified Wenjing decoction. The patients in the two groups were continuously treated for three menstrual cycles. The treatment effects, the dosage of analgesics, the scores of associated symptoms before and after treatment, and other indexes were compared between the two groups.  The materials of 111 patients with primary dysmenorrhea of cold coagulation and blood stasis in the outpatient department (January 2019–June 2021) were collected to conduct the retrospective study. The 111 patients were randomized into treatment group (P < 0.05). Compared with the control group, the treatment group had lower scores of associated symptoms after treatment (p < 0.5). After the treatment of three menstrual cycles, 54 patients in the treatment group stopped taking ibuprofen, and the average ibuprofen dosage of the other 5 patients was (0.24 ± 0.16)g. The 52 patients in the control group still needed to take ibuprofen, and the mean dosage was (0.51 ± 0.05)g. The differences in the ibuprofen dosage between the two groups had remarkable difference (P < 0.001).  The differences in the efficacy on abdominal pain were statistically significant between the two groups ( Modified Wenjing decoction combined with online publicity and education can obviously improve the clinical symptoms of the patients with primary dysmenorrhea of cold coagulation and blood stasis and reduce the dosage of analgesics. It is worth promoting and applying in practice. Primary dysmenorrhea, as a common gynecological disease in clinic, features such symptoms as periodic abdominal pain, lumbosacral dragging pain, and even syncope due to megalgia during or around menstruation. Dysmenorrhea can be divided into primary dysmenorrhea and secondary dysmenorrhea. The former, also known as functional dysmenorrhea, has no organic lesion in pelvic cavity and often occurs within a few years after menarche. The latter is mainly caused by pelvic diseases such as endometriosis, so it is called secondary dysmenorrhea. Compared with secondary dysmenorrhea, primary dysmenorrhea is more common. It may happen to the women after 1-2 years of the menarche or after the age of 40, severely affecting their daily work and life. At present, the modern medicine has not clearly explained the pathogenesis of primary dysmenorrhea, which is commonly attributed to the contraction of uterine smooth muscle caused by the elevated prostaglandin in the endometrium. Hence, the main treatment for primary dysmenorrhea is taking prostaglandin inhibitors in the modern medicine [The traditional Chinese medicine (TCM) believes that primary dysmenorrhea is closely related to cold pathogen. During or around menstruation, the blood filling in Xuehai overflows and qi-blood suddenly becomes deficient from vigorous. As a result, the women are susceptible to pathogenic factors because of the relative insufficiency of healthy energy and the sharp changes of qi and blood in the uterus and Chong and Ren meridians . If the n = 59) and control group (n = 52). In the treatment group, the mean age was (31.58 ± 8.08) years old and the mean duration of disease was (30.32 ± 5.97) months. In the control group, the mean age was (29.31 ± 7.53) years and the mean duration of disease was (30.30 ± 6.88) months. The differences in age, duration of disease, and the scores of associated symptoms before treatment between the two groups had no statistical significance (P > 0.05), and the two groups were comparable.All the 111 patients were from the outpatient department (January 2019–June 2021) and met the diagnostic criteria for primary dysmenorrhea of cold coagulation and blood stasis. They were randomized into treatment group . The secondary symptoms were little menstrual volume, impeded discharge of menses, dark or clotting menstrual blood (the pain reduced when the blood clots were passed out of the body), pale complexion, fearing of cold, chilly extremity, cold sweat, nausea, vomiting, and diarrhea, which affected the work and study.Cinnamomum cassia, 20 g of Chinese angelica root, 20 g of root of herbaceous peony, 12 g of Chuanxiong Rhizome, 20 g of Corydalis, 15 g of motherwort, 9 g of safflower, 20 g of Pilose Asiabell root, 20 g of eucommia bark, 20 g of Himalayan teasel root, and 15 g of malaytea scurfpea fruit. The patients took one dose a day with boiled water in the morning and at night. The patients began to take the granules three days before the menstruation, took them for six consecutive days, and continuously received such a treatment for three menstrual cycles.The patients were given modified Wenjing decoction. In the first course of treatment, they orally took ibuprofen when they felt obvious pain. In the second and third courses of treatment, the ibuprofen was discontinued and the improvement on pain was observed. When the patients felt obvious pain, they could orally take ibuprofen again. To ensure the stable quality of the Chinese medicine and avoid the impact of decocting process on the efficacy, the TCM formula granules (CR Sanjiu or Guangdong E-Fong) were selected for the treatment. The prescription ingredients were as follows: 9 g of medicinal evodia fruit, 9 g of Chinese Thorowax root, 9 g of The patients began to take ibuprofen tablets  from the first day of the menstruation cycle, 0.2 g one time, 3-4 times a day. The patients with severe pain could increase the dosage. The course was generally 1–3 days.The health publicity and education were performed through private WeChat and WeChat Official Account for the patients, and their relevant consultations were answered in time. The patients were guided to maintain a good mood, have a light diet, and avoid eating raw, cold, and irritating food during menstruation. Besides, proper exercises before and after menstruation, such as yoga and Pilates, were also recommended, which could enhance uterine blood circulation and improve uterine arterial blood flow. During nonmenstrual period, the patients could properly adopt the external treatment, such as moxa-wool moxibustion and local hot compress, which could ease the symptoms of dysmenorrhea to a certain extent.Guiding Principles for Clinical Study of New Chinese Medicines [The criteria were formulated according to edicines . If the Guiding Principles for Clinical Study of New Chinese Medicines. The associated symptoms included pale complexion, cold sweat, chilly extremity, and waist soreness. The patients with pale complexion and waist soreness were scored 0.5 point, and the patients without were scored 0 point; the patients with cold sweat and chilly extremity were scored 1 point, and the patients without were scored 0 point. The scores of associated symptoms before and after treatment of the two groups were recorded.The scores were determined according to The ibuprofen dosages after the treatment of three menstrual cycles of the two groups were recorded.X2 test and t test. When P < 0.05, the differences were considered statistically significant.This study adopted SPSS 20.0 as the data processing software. The study included count data and measurement data and used P < 0.05; The differences in the efficacy on abdominal pain between the two groups had statistical significance .In the treatment group, 54 patients stopped taking ibuprofen after the treatment of three menstrual cycles, and the average ibuprofen dosage of the other 5 patients was (0.24 ± 0.16)g. After the treatment of three menstrual cycles, the 52 patients in the control group still needed to take ibuprofen, and the mean dosage was (0.51 ± 0.05)g. The differences in the ibuprofen dosage between the two groups had statistical significance  under the action of cyclooxygenase. The active prostaglandin leads to dysmenorrhea –8. At prCinnamomum cassia; the second type is the drugs promoting blood circulation to restore menstrual flow, including motherwort and safflower; the third type is the drugs promoting blood circulation to arrest pain, including Chuanxiong Rhizome and Corydalis; the forth type is the tonic drugs which tonify qi, yang, and blood, including Pilose Asiabell root, eucommia bark, Himalayan teasel root, malaytea scurfpea fruit, Chinese angelica root, and the root of herbaceous peony. The four types of drugs produce effects in accordance with the pathogenesis of primary dysmenorrhea of cold coagulation and blood stasis. The blood coagulates due to the cold and flows with the heat. The modified Wenjing decoction proposes adopting the warm-hot natured drugs to warm up and dredge the uterus and Ren and Chong meridians. On the one hand, these drugs can dispel cold to enhance the blood circulation; on the other hand, these drugs, companied with tonic drugs, can warmly nourish yang qi. For the patients with dysmenorrhea caused by kidney deficiency cold syndrome and endogenous cold, the temperature of their uterus and meridians is low and they suffer from blood stasis and menstrual obstruction. The warm-hot natured drugs companied with tonic drugs is suitable for these patients in particular. The drugs promoting blood circulation to restore menstrual flow have the effects of removing blood stasis and alleviating pain caused by cold pathogen. The drugs promoting blood circulation to arrest pain, on the one hand, can be combined with the warm-hot natured drugs to warmly dredge meridians. On the other hand, the combination of these drugs and the third type of drugs can replenish qi, activate blood circulation, remove blood stasis, and alleviate pain. Tang Yifeng pointed out in his paper that the analgesic potency of the total alkaloids in Corydalis was 40% of morphine. Among the total alkaloids, tetrahydropalmatine has the strongest analgesic effect. Its analgesic effect is weaker than morphine, but better than aspirin, and its analgesic effect on dull pain is better than that on acute pain. It has less side effects and no addition, so it is safe [According to TCM theory, the main cause of primary dysmenorrhea is cold pathogen, which can be divided into excess cold and deficient cold. If yang energy is deficient in the body, the cold will be generated from the inside and the women will suffer from it. If the healthy energy is deficient, the cold pathogen will intrude into the body and the blood will coagulate. As a result, the patients suffer from pain caused by the obstruction of the uterus and meridians. Besides, the pain may also result from the stagnation of qi and blood stasis, or qi-blood deficiency and the lack of nourishment of the uterus and meridians , 10. For is safe . The car is safe . The ton is safe . Asperos is safe . Malayte is safe . The comIn conclusion, modified Wenjing decoction combined with online publicity and education can obviously improve the clinical symptoms of the patients with primary dysmenorrhea of cold coagulation and blood stasis, can reduce their dependence on analgesics, and is conducive to radically cure the primary dysmenorrhea, so it is worth promoting and applying in practice.


There was no strong evidence of a correlation between sex and VAS scores. There were statistically significant correlations for BMI vs. pre-injection VAS with activity scores and Age vs. pre-injection VAS with activity scores . Mean WOMAC scores improved from 44.7 to 18.5 over 24 weeks (p < 0.001). 77.8% of patients who used medications at the beginning of the study reduced or eliminated medication use. The analysis demonstrates that injections with UCT decrease pain, improve physical function, and allow for less medication use for at least 24 weeks.To determine if knee pain subjects who received cryopreserved umbilical cord tissue (UCT) injected into knee joints experience less knee pain, better function, decreased physical limitations, and reduction of medications  over a 24 week period, Visual Analog Scale (VAS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and medication usage data were recorded for 30 consenting human knee pain subjects receiving UCT at a single site in the United States. Subject profile information was gathered and analyzed to gain insight into the effects of age, sex, and BMI on improvement over time. Mean resting VAS scores and mean VAS scores with activity improved over 24 weeks (from 1.95 to 0.83 and from 6.28 to 2.87, respectively,  Osteoarthritis (OA), the most common type of disease affecting joints, is one of the most predominant causes of chronic pain and disability in developed nations, including the United States. Specifically, knee OA represents over 80% of the types of osteoarthritis, affecting almost one-fifth of American adults over the age of 45 years . Almost Senescing joint tissues accumulate more cartilage loss due to inflammation, oxidative stress, and matrix metalloproteases (MMP) activation . Joint rCurrent treatments for joint pain are limited, and include medical management, injection therapy, and surgery. Pain medications are linked with significant morbidity and social concern. Over the course of the year 2019, 10.1 million people over the age of 12 years misused opioids, the overwhelming majority of which were prescription pain relievers. Of those, approximately 1.6 million people over the age of 12 years were diagnosed with an opioid use disorder [Non-steroidal anti-inflammatory drugs (NSAIDs) are often the first treatment tried by patients suffering from chronic pain. Hospital admission rates due to upper and lower gastrointestinal events secondary to NSAID and aspirin drug use were significant with a mortality rate of almost 6% of admitted patients. About 30% of these deaths were attributed to the use of low-dose aspirin . While mWhile steroid injections provide short-term relief of pain, side effects such as diabetes exacerbation, weight gain, cataracts, osteoporosis, difficulty sleeping, menstrual changes, and increased risk of infection should be considered . DiseaseAnother possible injectate, viscosupplementation, often requires multiple injections of hyaluronate. Patients experience relief for only 8–12 weeks, if at all . These tFinally, surgery for joint replacement associated with chronic pain is very costly and may have a limited effect on pain and disability ,8. GivenAnother option is umbilical cord tissue (UCT) which is available for clinical use from registered global tissue banks. Methods of preparation and forms of umbilical cord tissue allografts may vary, affecting the specific contents and clinical results. 2 (PGE2), interleukin-10, vascular endothelial growth factor, and tissue inhibitors of metalloproteinases that suppress cartilage damage. These proteins exhibit powerful anti-inflammatory and anti-fibrotic effects in osteoarthritic joints [UCT from healthy live births contains regenerative, anti-inflammatory, immunomodulatory, and wound-healing properties due to the many growth factors and cytokines present in UCT at a higher concentration than in other biologics. These may play a factor in their inflammation-reducing, pain-reducing, and musculoskeletal-healing properties ,18. UCT c joints ,20. PGE2c joints . UCT stic joints ,23,24,25This study was conducted under an Advarra IRB-approved protocol (Pro00040024), and we obtained informed consent from all patients.Placental and umbilical cord tissue donated by volunteers, screened and free of viral and bacterial disease, undergoing caesarian section was processed to obtain UCT. The UCT was minimally manipulated under aseptic conditions and cryopreserved with dimethyl sulfoxide (DMSO) 10% solution, retaining a large amount of its initial matrix microstructure and cytokine profile. The samples were sent off to an outside laboratory to confirm the sterility of the product and freedom from endotoxins. The product was then shipped to the end user on dry ice and then transferred to a −80 °C freezer until use. The cryopreserved UCT was used homologously as a cushion or protective barrier of membranous tissue placed in or over damaged joint tissue in patients with joint pain due to osteoarthritis. Previous conventional medical management, such as pharmacological and physical therapy, failed for the patients receiving UCT for joint pain, making it medically necessary to proceed with interventional treatment. After patient education and consent, the human patient underwent an ultrasound-guided lateral suprapatellar injection utilizing 1 mL of thawed cryopreserved UCT along with 4 mL sterile normal saline under direct ultrasound visualization after the knee was prepped with alcohol. The product was thawed to room temperature and was then diluted to a volume wherein the amount of DMSO injectate was 2.5%. The needle utilized was a 22 gauge 1-½ inch needle. The post-procedure evaluation involved alertness, pain, stable vital signs, and unchanged neurologic status after 15 min. The patient was discharged in stable condition with postoperative instructions. While UCT knee injections are a daily practice at this clinic, outcomes have not been adequately reported. The fact that these patients failed conservative measures was a prerequisite to imply a clinical control. The pre-condition was used as a control. To report outcomes after UCT injection for joint pain, medical charts of 30 consenting adult subjects with knee joint pain were reviewed for Visual Analogue Scale (VAS) pain scores , WesternThe pain was assessed by the patient using the VAS before the UCT injection as a baseline and after 1 h, 24 h, 1 week, 2 weeks, 8 weeks, 12 weeks, and 24 weeks of the UCT injection for both resting scenarios and with activity scenarios. Pain levels were subjective complaints utilizing the Visual Analogue Scale from 1–10. Patients rated their pain as per the VAS scale at rest and while engaging in normal activities of daily living. These were further supported using the WOMAC. Pain, stiffness, and physical function were assessed using the WOMAC questionnaire before the UCT injection as a baseline, and 2, 8, 12, and 24 weeks after the UCT injection. The use of opiates, NSAIDs, and other medications was recorded before the UCT injection as a baseline and 24 h, 1 week, 2 weeks, 8 weeks, 12 weeks, and 24 weeks after the UCT injection.All the data were analyzed by analysis of variance (ANOVA) followed by post hoc analysis, which differed depending on the data set being analyzed . Medical records for 30 patients presented substantially comprehensive data regarding demographics and outcomes. The mean age was 63.0 ± 10.9 years with a range of 36–84. t-tests. However, a statistically significant correlation was found between age and the pre-injection VAS (resting) score , showing higher pre-injection VAS (resting) scores for older patients. There was no statistical difference found between the sexes and VAS scores (resting or with activity) at the 24-week review, based on independent sample Two-thirds of the patients received treatment for their right knees, and one-third received treatment for their left knees. The patient population’s body mass index (BMI) was 29.2 ± 7.0 with a range of 18.0–50.2 . p = 0.028), showing a higher pre-injection VAS (with activity) score for patients with a higher BMI.A statistically significant correlation was found between BMI and the pre-injection VAS (active) score , while mean VAS scores (with activity) improved from 6.28 to 2.87 (p < 0.001) for the same period.Mean VAS scores (resting) improved from 1.95 to 0.83 over 24 weeks  than the mean VAS scores at rest for every time interval.Mean VAS scores with activity at baseline were statistically different (higher) than the mean VAS scores with activity for every post-injection time interval;p-value for the ANOVA for VAS scores with activity was 1.18 × 10−15;The Overall, there was a decrease in the mean for VAS with activity scores after the injection.Mean VAS scores at rest were statistically different (higher) than the mean VAS scores at rest for every time interval;p-value for the ANOVA for VAS scores at rest was 0.000561;The Overall, there was a decrease in the mean for VAS at rest scores after the injection.Graphical representation of the mean VAS scores (at rest and with activity) over time with standard deviation is shown in The Mack-Wolfe test is a non-parametric technique used to test for a U or umbrella shape in the median . It works even when the curve is very non-symmetrical about the valley . Execution of the Mack-Wolfe test on the VAS scores revealed that there was strong evidence of a valley in the VAS (resting) score median at 8 weeks and a valley in the VAS (with activity) score median at 2 weeks. See p < 0.001). ANOVA for WOMAC scores over the 24-week review period revealed that the mean pre-injection WOMAC score was statistically different from the mean WOMAC scores at 2 weeks, 8 weeks, 12 weeks, and 24 weeks. This is supported by a p-value of 1.34 × 10−6. Otherwise, the mean WOMAC scores at 2 weeks, 8 weeks, 12 weeks, and 24 weeks were not statistically different from each other. Graphical representation of the mean WOMAC scores over time is shown in WOMAC-measured physical function scores improved from 44.7 to 18.5 over the 24-week review period (p = 0.1972), suggesting further data need to be collected over a longer period to draw a strong conclusion; however, this linear model suggests it would take an estimated 1162 days  to return to pre-injection VAS with activity scores without further intervention. , model reduction may improve the model.The lack of fit F-value of 0.38 implied that the lack of fit was not significant relative to the pure error. There was an 82.49% chance that a lack of fit F-value this large is due to noise. Non-significant lack of fit is good, as we wanted to model the fit. A quadratic model was tried but it did not improve the model fit. The model is described below:Given that the average pre-VAS score was 6.28333, we estimated that it would take about 1162 days post-injection (3 years and 8 weeks) for VAS scores to return to pre-Injection levels, on average.Overall, of the patients who used medications at the beginning of the study (18), 77.8% of them reduced or eliminated medication use, as shown in 30% (n = 9) of the patients studied never took medication throughout the course of the study period;13.3% (n = 4) of the patients studied continued to take medications throughout the entire course of the study period;20% (n = 6) of the patients studied went from daily medication use to no medication use by the end of the study period;13.3% (n = 4) of the patients studied reduced their medication frequency from daily to occasional by the end of the study period;13.3% (n = 4) of the patients studied reduced their medication frequency from occasional to none by the end of the study period;One person went from using no medications to using CBD oil on the knee at the end of the study period. Although that patient had decreasing WOMAC and VAS at rest scores throughout the study period, their VAS with activity score did not change significantly throughout the study period (VAS range: 3–4);One person went from using no medications to occasionally using acetaminophen at the end of the study. This patient’s VAS and WOMAC scores remained consistent throughout the study;One person went from using no medications to using acetaminophen or ibuprofen daily. This person’s VAS and WOMAC scores initially decreased after the injection, but increased back up over time to pre-injection scores;The number of patients using opioids decreased by 16.7% from pre-injection to 24-week follow-ups, and the number of patients using NSAID decreased by 46.1% from pre-injection to 24 weeks follow.Analysis of medication use by patients over the study period revealed:t-test showed strong evidence of a difference for VAS with activity scores and those using medications; that is, subjects using medications reported higher VAS active scores .Medication data were binarized at 24 weeks (any medicine vs. none). A Welch two-sample No serious adverse events were reported throughout 24 weeks. Between 8 and 12 weeks, one patient fell and reinjured the knee and was reinjected at 5 months. The late intervention was without complication. All three outcomes represent a consistent result with significant improvement over time. Extended follow-up is expected at 52 weeks for all patients. A chart review of 30 patients with joint pain showed the clinical benefits of injecting UCT for knee pain. Improvements in pain and physical function and a reduction in medication use (opiates and NSAIDs) began promptly after treatment. It was sustained over at least a 2-week period, extending to 24 weeks in most cases. UCT offers an important alternative to opiate use, a national CDC epidemic due to dependency, overdose, and abuse, with related difficulty managing patients on opiates ,10.In many instances, patients were physically limited and deconditioned secondary to their pain. Counseling on weight reduction and a transition to physical activity is a key adjunctive measure in achieving improvement in normal activities. Prior to treatment, many patients exhibited increased BMI and were physically deconditioned. This is a factor that may complicate or hinder recovery and functional restoration. Therefore, patients must be counseled on the reduction in BMI for sustained outcomes. This study demonstrated that the injections were effective for 24 weeks; however, we have continued to follow these patients over the course of 2 years. We have observed that many patients experience more than 24 months of relief compared to baseline with just one injection. This is consistent with the extrapolation projection, as demonstrated in our ANOVA linear model . While a single steroid injection is less expensive than a single UCT injection, a patient may receive up to four steroid injections each year, increasing the morbidity associated with each injection. This is compared to UCT, which requires only one injection and has not been associated with any adverse events or increased morbidity and may provide several years of relief. While this review supports safety and efficacy, its limitation is that it is not a double-blinded randomized study. Additional studies must confirm the data substantiating pain relief and improved function in patients with arthritic joint pain before acquiescing to joint replacement.In conclusion, UCT injections reduce pain, physical incapacity, and medication use  in patients experiencing knee pain for at least 24 weeks. As a result, this would allow patients to postpone or delay joint replacement until BMI and physical condition is optimized.


The aim of this study was to explore the differences between local myalgia and myofascial pain with referral by means of a biopsychosocial model based on the DC/TMD.The Diagnostic Criteria for Temporomandibular Disorders (DC/TMD) categorized TMD muscle disorders into 3 subgroups: local myalgia, myofascial pain with spreading and myofascial pain with referral. However, the rationale for such division into subgroups and the pathogenesis and prognosis of muscle-related TMD are still poorly understoodp value < 0.05 was considered statistically significant.This retrospective study included all consecutive TMD patients who were diagnosed according to the DC/TMD in our institution between 2015 and 2018. The Axis I and II findings of patients diagnosed with local myalgia were compared to those of patients with myofascial pain with referral. A p = 0.006 compared to p = 0.033 for depression total score, and p = 0.001 compared to p = 0.046 for nonspecific physical symptoms total score). CPI levels, extent of disability, and pain duration were similar for both groups when excluding for HAattrTMD.A total of 255 patients  were enrolled into the study, 114 in the local myalgia group and 83 in the myofascial pain with referral group. The levels of depression and nonspecific physical symptoms, headache attributed to TMD (HAattrTMD), and characteristic pain intensity (CPI) were significantly higher in the latter group. The significant differences for depression and nonspecific physical symptoms persisted after excluding patients diagnosed with HAattrTMD, however, the levels of significance were lower (The current study findings highlight the importance of differentiating between subgroups of myalgia according to the DC/TMD. The diagnosis of myofascial pain with referral may point to a significant Axis II component. Temporomandibular disorders (TMD) are defined as "a group of musculoskeletal and neuromuscular conditions that involve the temporomandibular joints (TMJs), the masticatory muscles, all associated structures of mastication, and associated tissues" . DiagnosMuscle-related disorders represent the largest subgroup among the various TMD diagnoses . The RDCThe 2 diagnoses are closely related to jaw function and differ only by the ability to create local versus referred pain beyond the boundary of the muscle being palpated. As such, the basis for differentiating between them is purely clinical. It should be noted that although diagnostic criteria for all subgroups of muscle-related pain were established in the DC/TMD, the pathogenesis and prognosis of muscle-related TMD is still poorly understood. Several central and peripheral theories have attempted to explain the pathophysiology underlying myofascial pain with referral –9. The pHowever, so far only few studies have examined the differences between local myalgia and myofascial pain with referral by applying the DC/TMD –17. TherThe current study was performed following the recommendation of the co-lead authors , 23 of tThe study was approved by the Tel Aviv University Institutional Ethical Committee prior to data collection (#14134_20180327). Informed consent was waived since the data were retrieved retrospectively. However, each patient who is referred to the "Orofacial and TMD Clinic" routinely signs a form in which s/he agrees that his/her data can be anonymously used for research purposes. The study was self-funded by the authors.This retrospective study population included 558 consecutive patients who were seen for the first time in the Tel Aviv University Orofacial Pain Clinic during 2015–2018. All the patients were examined by senior staff members certified in the DC/TMD Training and Calibration Course at the Department of Orofacial Pain and Jaw Function at the Faculty of Odontology at Malmö University, Sweden. Each patient who was suspected as having TMD underwent a full DC/TMD Axis I and Axis II evaluation according to the official Hebrew version  of the DThe following instruments were used to evaluate Axis II: depression level [Patient Health Questionnaire (PHQ)-9], nonspecific physical symptom levels (PHQ-15 questionnaire for somatic symptoms), anxiety level [Generalized Anxiety Disorder (GAD)-7]. Characteristic pain intensity (CPI), pain persistence classification, and Graded Chronic Pain Scale (GCPS) version 2.0 were calculated for each patient according to the specifications of the DC/TMD. Excluded from the study were 56 patients who did not complete the DC/TMD questionnaire, 67 patients who were younger than 18 years, 142 patients who received other orofacial pain diagnoses that included systemic diseases , and 38 patients who did not meet the DC/TMD criteria for diagnosis of TMD, leaving a total 255 TMD patients. The final study population was comprised of 197 patients who received Axis I muscle-related diagnosis, 114 of whom were diagnosed as having local myalgia and 83 patients diagnosed as having myofascial pain with referral  and standard deviation (SD) and analyzed by non- parametric tests. Categorical variables were described as frequency and percentage. The Pearson chi-squared test and Fisher's Exact test were used to test the associations between categorical variables. The Mann–Whitney test was used to assess differences in continuous variables between categories. All tests were 2-tailed. IBM SPSS Statistics for Windows, Version 25.0. Armonk, NY: IBM Corp. was used for all statistical analyses. A Overall, among the 255 TMD patients, the female:male ratio was 3:1, and the mean age ± SD was 37 ± 15.3 years. The Axis I painful diagnoses were local myalgia in 114 patients (44.7%), myofascial pain with referral in 83 patients (32.5%), arthralgia in 50 patients (19.6%), and HAattrTMD in 60 patients (23.5%). The Axis II results showed that 42 patients (16.5%) reported high levels of disability (GCPS levels 3–4), 20 (7.8%) scored moderately severe-severe on the depression questionnaire (PHQ-9), 13 (5.1%) scored severe on the anxiety questionnaire (GAD-7), and 10 (3.9%) scored severe on the nonspecific physical symptoms questionnaire (PHQ-15). 70 (27.5%) of the patients reported persistent pain in the last 30 days.n = 114) and a second group diagnosed as having myofascial pain with referral (n = 83). The demographic and socioeconomic characteristics of the 197-patient cohort are listed in Table p = 0.043). Only 5 (6.3%) of the myofascial pain with referral group reported very low-low income, compared to 18 (16.7%) of the local myalgia group.In the first stage of the study, only patients with muscle-related disorders were included. They were divided into 1 group diagnosed as having local myalgia (p = 0.217), headache duration (p = 0.295), and pain persistence score (p = 0.363). However, the myofascial pain with referral group reported significantly more headaches during the preceding 30 days (p = 0.002) and higher pain intensity (p = 0.033).Table p < 0.001).Table p = 0.006) and PHQ-15 , which were significantly higher in the myofascial pain with referral group. Significant differences were found in interference score (p < 0.001). The 2 groups did not differ in their disability scores  (p = 0.763).Table n = 45) were compared with patients with local myalgia (n = 99). Tables In the second stage of the study, patients diagnosed with HAattrTMD were removed from both groups, and patients with myofascial pain with referral n = 4 were comp = 0.006 compared to p = 0.033 for the total depression score, and p = 0.001 compared to p = 0.046 for the total nonspecific physical symptoms score).Table The purpose of this study was to explore the differences between local myalgia and myofascial pain with referral as measured by the biopsychosocial model according to the DC/TMD. The results suggest that TMD patients diagnosed with myofascial pain with referral may have a significant Axis II component. These results support the findings of a recent study by Barjandi et al.  that shoIndeed, numerous studies have suggested that myofascial pain with referral results in the induction of central sensitization after ongoing peripheral nociceptive stimuli –28, implImportantly, the current study demonstrated higher levels of Axis II irrespective of pain duration and pain intensity. This highlights that aside from pain duration and intensity other components contribute to persistence of TMD, such as genetic factors, environmental contributions, life stressors, autonomic function, and impaired pain regulation –44.In the current study, the more widespread the pain (including HAattrTMD diagnosis) the more apparent were the differences in pain level, and the greater was the increase in the level of significance of the Axis II findings, including interference score which was higher in the myofascial pain with referral group which included patients with diagnosis of HAattrTMD. While no findings in disability levels and pain duration were found in the current study, it was previously shown that the diagnosis of HAattrTMD was associated with myofascial pain with referral, significantly higher Axis II results, greater disability, and higher pain levels, but no differences in pain duration compared to painful TMD patients without diagnosis of HAattrTMD . These fThe current study findings of significantly higher Axis II levels in the myofascial pain with referral group also raise the possibility of identifying potential future chronic TMD patients as early as the first visit with the sole use of Axis I findings of myofascial with referral according to the DC/TMD. This may be of significant clinical value, especially in situations where Axis II information is not available, and only Axis I information is used for diagnosis according to the DC/TMD , 19, 50.The current study could not answer the question of whether local myalgia and myofascial pain with referral represent different entities. As observed by Michelotti et al. , it is pThe current study highlights the importance of differentiating between subgroups of myalgia according to the DC/TMD, specifically local myalgia and myofascial pain with referral, for both clinical and research purposes. The findings suggest that a diagnosis of myofascial pain with referral may be indicative of a significant Axis II component which may require a tailored treatment approach in order to try to prevent transference to a chronic pain condition. Finally, a higher score of an Axis II component may be expected in association with more widespread pain, including HAattrTMD.


Musculoskeletal pain is commonly experienced in patients with Parkinson's disease (PD). Few studies have investigated the clinical characteristics and risk factors associated with musculoskeletal pain.To investigate the distribution, clinical characteristics, and factors associated with musculoskeletal pain in a large sample of patients with PD.We enrolled 452 patients from two clinics and used a standardized questionnaire to collect demographic and clinical information. Musculoskeletal pain was diagnosed based on the Ford Classification System, and pain severity was assessed with the numeric rating scale (NRS). Multivariate regression models explored the association between clinical features of PD and quality of life and pain.p = 0.017), motor symptoms (p < 0.001), and depression (p < 0.001) were significantly associated with quality of life.Two hundred and six patients (45.58%) reported musculoskeletal pain, typically in their lower limbs and backs. Levodopa resulted in a ≥30% reduction in pain intensity scores in 170 subjects. Female sex  and Levodopa-equivalent daily doses  were associated with an increased risk for musculoskeletal pain. Pain duration (The lower limbs and back are common sites of musculoskeletal pain in patients with PD, and up to 82.52% of patients were responsive to Levodopa. Female sex and LEDDs are associated with musculoskeletal pain, suggesting that dopamine deficiencies, and not the motor and non-motor impairment, might be the most critical baseline risk factor of musculoskeletal pain. Pain is an important non-motor symptom of Parkinson's disease (PD), with an estimated prevalence of 40–83% . Pain caMusculoskeletal pain is the cause of pain in 40–90% of patients with PD , 5. HoweIt is well-known that Levodopa is the most effective treatment for the motor symptoms of PD and can also alleviate MSP . HoweverThis study investigates the clinical characteristics and associated factors of MSP to better understand the etiology of MSP in a large sample of patients with PD in China.All the study procedures were performed following the principles of the Declaration of Helsinki and the institutional review boards of the Xuanwu Hospital  and the First Affiliated Hospital of the Anhui University of Traditional Chinese Medicine . Each participant provided written informed consent.Consecutive outpatients with idiopathic PD who visited the movement disorders clinic of Xuanwu Hospital of Capital Medical University and the Neurology Department of the First Affiliated Hospital of the Anhui University of Traditional Chinese Medicine between July 2017 and January 2020 were enrolled. The inclusion criteria were (a) idiopathic PD diagnosed according to the 2015 Movement Disorder Society (MDS) clinical diagnostic criteria ; (b) ageMusculoskeletal pain was diagnosed by the Ford Classification System  for painAll patients were asked to indicate the distribution of pain sites, duration of pain, and rate average pain intensity over the past 3 months on an 11-point numeric rating scale (NRS) , with 0 We used the MDS-Unified PD Rating Scale (MDS-UPDRS) to measure motor symptoms in the ON and OFF states. The Hamilton Depression Scale (HAMD), Hamilton Anxiety Scale (HAMA), PD Sleep Scale (PDSS), and PD Questionnaire (PDQ-39) were used to assess the severity of depression, anxiety, sleep quality, and QoL, respectively. The type and dose of PD medications at the time of assessment were recorded. Levodopa-equivalent daily doses (LEDDs) were calculated using the formulae described by Tomlinson et al. . The usep < 0.05. Clinical and demographic data were represented as mean ± SD, median with 25–75% interquartile range (IQR), or number (%). The Shapiro–Wilk test showed that our data for NRS scores (ON/OFF state) are not normally distributed. We used the non-parametric Wilcoxon signed-rank test to compare the NRS scores reported in the ON state with those reported in the OFF state. We calculated the proportion of pain in the ON/OFF state for every pain severity category in the MSP group.Statistical analyses were performed with SPSS version 23 . Statistical significance was defined as t-test for continuous variables and the χ2-test for categorical variables to compare the patients who reported MSP and those who did not. The Box-Tidwell method was used to evaluate the linear relationships between continuous independent variables and the logit transformed dependent variable. The variables that exhibited significant between-group differences in these univariate analyses were entered into a multivariable binary logistic regression model with stepwise (forward) to calculate odds ratios (ORs) and 95% CIs to identify predictors of MSP.Each patient was assigned 1 point if MSP was present or 0 if absent. The cut-off scores of HAMA, HAMD, and PDSS are 7 points for anxiety, 8 for depression, and 105 for sleep disorders, respectively. We used a To investigate the PDQ-39 domains associated with MSP, we first conducted a Pearson correlation analysis to determine candidate factors among the continuous variables. Then, we used multiple linear regression analysis to identify the genuinely relevant variables, and the regression analyses were corrected for the potential confounders.p = 0.046), had a higher proportion of females , a longer disease duration , higher MDS-UPDRS part I scores , and higher doses of LEDDs . There were no significant differences in the MDS-UPDRS part III, MDS-UPDRS part IV, HAMD, HAMA, PDSS, PDQ scores, and the Hoehn and Yahr scale between groups.A total of 452 patients were included in the analyses. The demographics and clinical characteristics of the study population are described in n = 160; 77.67%), upper and lower back , upper limbs , hands and wrists , shoulders , ankles and feet , neck , whole-body , pelvic region and thighs , and head   . Patientp < 0.001).All patients received antiparkinsonian drugs. Of the 206 patients with MSP, 170 (82.52%) reported that MSP was responsive to Levodopa, as indicated by reducing pain with at least 30% improvement over a short period, whereas 36 patients (17.48%) showed no response. Of the non-responsive patients, one reported that MSP was worsened by Levodopa and alleviated when the Levodopa dose was reduced. In general, the NRS scores recorded in the ON state after Levodopa treatment  were lower than those recorded in the OFF state before Levodopa treatment  and LEDDs . PD duration, MDS-UPDRS part III score in the OFF state and MDS-UPDRS part IV, PDSS (≥105 or <105), HAMD (≥8 or <8), and HAMA (≥7 or <7) scores were not significantly associated with MSP.p < 0.001), HAMD scores , and MSP durations  were significantly positively related to PDQ-39 scores. The MDS-UPDRS part IV, HAMA, PDSS, and NRS scores and ages were not related to PDQ-39 scores.In the present study, we found that 45.58% of patients with PD experienced MSP. The distribution of MSP was variable and associated with various sensations. MSP was responsive to Levodopa therapy, and female sex and higher LEDDs were identified as risk factors for MSP. There was a significant association between longer MSP durations and reduced QoL.We found that lower limbs and back pain were the most common sites. Similar results were reported in a previous study, demonstrating that MSP prevalence in specific body parts ranged from 20 to 60%. Among them, MSP in the back and lower limbs have the highest prevalence . Other sConsistent with previous reports , LevodopAs noted, female sex was a risk factor for MSP in our study; this observation is consistent with those of previous studies showing that women are more likely to have MSP across all age groups than men , 20. A sIn addition to the female sex, LEDD was also a risk factor for MSP in our logistic regression analysis. A previous study reported LEDD as a related factor associated with higher pain scores but not a risk factor . In thisFurthermore, our analyses identified no relationship between MDS-UPDRS part III scores and MSP presence, and other studies also reported similar findings , 29. Somr = 0.11), depression (r = 0.16), or anxiety (r = 0.2) reported in that study was weak. Furthermore, the previous study did not include additional analyses, such as logistic regression, which could be influenced by various confounding factors that affected the presence of MSP. This may explain the discrepancy between our results and those of the previous study. The lack of a relationship between motor symptoms and MSP is consistent with the observations reported for other pain conditions. For example, in complex regional pain syndrome, which can occur in various movement disorders, motor disorders are not associated with abnormal sensory plasticity   . ThirdlyIn conclusion, our study shows that MSP commonly occurs in patients with PD, affecting multiple body parts with various sensations. The most common MSP sites are the lower limbs and back. Levodopa therapy can alleviate MSP with an 82.52% response rate. Women and higher LEDDs are more likely associated with a higher risk of MSP than PD-related motor symptoms, which has substantially changed our understanding of PD with MSP. The observation that pain duration is an important determinant of QoL reinforces the need for future strategies aimed at improving MSP.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.Written informed consent was obtained from the individual(s) for the publication of any potentially identifiable images or data included in this article.JL designed the study, interpreted the results, and wrote the manuscript. B-FZ designed the study, collected the data, and analyzed the data. S-SM, S-ZJ, and H-ZC collected the data. S-YL and CH advised the methodology and interpreted the results. Z-QG and HZ revised the manuscript. PC supervised the study, revised the manuscript, and is the study guarantor. All authors contributed to the article and approved the submitted version.This work was supported by the National Key R&D Program of China , Anhui University Science Research Project (Grant No. KJ2021A058), and the Outstanding Young Talents Project of Universities in Anhui Province Study Abroad (Grant No. gxgwfx2021028).The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Pain and anxiety can be difficult to control in the burn patient. Ketamine, a NMDA receptor antagonist can be utilized, however intravenous (IV) dosing requires increased monitoring. In contrast, oral ketamine (O.K.) is reported to have fewer side effects, and can be administered without a higher level of care. Little is known about dosing and efficacy of O.K. in the treatment of burn patients. We sought to examine the use of O.K. in our burn population.This was a cross-sectional comparative quality improvement study conducted at our ABA verified burn center from January 2021through September 2021. Inclusion criteria were in patients experiencing refractory pain and anxiety after receiving fentanyl and midazolam during wound therapy one day prior to first O.K. administration, along with completion of pre-post patient assessment surveys. Patients were administered 50mg-150mg of ketamine in an oral suspension mixed with 30mL-120mL juice. Effectiveness of the O.K. was measured using pre-post patient surveys, pre-post IV pain medication usage, and subjective staff evaluation of pre-post tolerance of debridement. Baseline demographics were recorded, along with adverse events. O.K. was deemed effective by improved survey scores, improved tolerance to debridement, and reduction in IV medication requirements. Students T-test was performed to determine significance.A total of 71 patients were given O.K, and 32 met inclusion criteria. Baseline demographics included: 19 male (59%), median age 36 years (range14-66), median TBSA 9.9% (range 1.6%-33.2%). O.K. reduced mean fentanyl use by 33%  and mean midazolam use by 39% . On a scale of 1-10  mean pain scores improved 38.8% , anxiety by 36.6% , and overall experience by 37.5% . Mean O.K. effective dose was 50mg. Staff noted O.K. improved the patient’s ability to tolerate debridement; uncooperative and inconsolable patients participated in their own wound care, and reported to prefer tub time with O.K. One patient experienced psychotomimetic effects, while one patient requested discontinuation due to increased anxiety 4 hours after O.K. administration.O.K. appears to be efficacious in improving pain and anxiety during wound care while being well tolerated by patients. It also subjectively improved the wound care therapy experience.