Background: Several studies have shown that patients with functional somatic syndromes (FSS) have, on average, deficient endogenous pain modulation (EPM), as well as elevated levels of negative affectivity (NA) and high comorbidity with depression and reduced resting heart rate variability (HRV) compared to healthy controls (HC). The goals of this study were (1) to replicate these findings and (2) to investigate the moderating role of NA, depression, and resting HRV in EPM efficiency within a patient group with fibromyalgia and/or chronic fatigue syndrome (CFS). Resting HRV was quantified as the root mean square of successive differences between inter-beat intervals (RMSSD) in rest, a vagally mediated time domain measure of HRV.Methods: Seventy-eight patients with fibromyalgia and/or CFS and 33 HC completed a counter-irritation paradigm as a measure of EPM efficiency. Participants rated the painfulness of electrocutaneous stimuli  on the ankle before (baseline phase), during (counter-irritation phase) and after (recovery phase) the application of a cold pain stimulus on the forearm. A larger reduction in pain in the counter-irritation phase compared to the baseline phase reflects a more efficient EPM.Results: In contrast to our expectations, there was no difference between pain ratings in the baseline compared to counter-irritation phase for both patients and HC. Therefore, reliable conclusions on the moderating effect of NA, depression, and RMSSD could not be made. Surprisingly, patients reported more pain in the recovery compared to the counter-irritation and baseline phase, while HC did not. This latter effect was more pronounced in patients with comorbid depression, patients who rated the painfulness of the counter-irritation stimulus as high and patients who rated the painfulness of the electrocutaneous stimuli as low. We did not manage to successfully replicate the counter-irritation effect in HC or FSS patients. Therefore, no valid conclusions on the association between RMSSD, depression, NA and EPM efficiency can be drawn from this study. Possible reasons for the lack of the counter-irritation effect are discussed. Endogenous pain modulation refers to the internal modification of pain signals in order to accommodate the body’s current and future needs . One exaFunctional somatic syndromes are disorders characterized by chronic and debilitating symptoms that are not sufficiently explained by an organic, identifiable disease. Although on average EPM efficiency seems to be reduced in FSS patients, EPM efficiency within the FSS population is heterogeneous . PresumaFibromyalgia and CFS are complex disorders, and the interaction between multiple biological, psychological, and social factors influence the onset and course of the symptoms . TherefoNext to elevated levels of depression and NA, patients suffering from fibromyalgia and CFS have, on average, lower levels of resting HRV . HRV refIn order to investigate the relationship between EPM and depression, NA, and HRV in FSS patients, patients diagnosed with fibromyalgia and/or CFS and HC went through a standard counter-irritation paradigm. Subjective pain elicited by electrocutaneous stimuli was assessed before, during and after counter-irritation with a CPAW. We expected that pain ratings elicited by the electrocutaneous stimuli would be lower during counter-irritation compared to pain ratings before counter-irritation, but that this pain reduction would be smaller in patients compared to controls, as has been found in previous studies . FurtherPatients were recruited in the Department of Psychiatry of the Ziekenhuis Oost-Limburg (ZOL) Hospital (Genk) and University Hospital Gasthuisberg (Leuven) and through the Rheumatology Center in Genk. Only patients with a doctor-based diagnosis for fibromyalgia, CFS, or both were included. Further, participants filled out a questionnaire to check for fulfillment of the 2010 ACR criteria for fibromyalgia  and the 2 inhalation by means of a rebreathing bag, gradually increasing FetCO2-levels, respiratory flow, and perceived dyspnea. Perceived dyspnea, respiratory flow, and FetCO2 levels were continuously measured during a room air baseline phase (60 s), rebreathing phase (150 s), and room air recovery phase (150 s). The third paradigm was a fear conditioning paradigm, in which an unconditioned stimulus (a picture of a fearful woman and an accompanying scream through the headphones) was paired with a conditioned danger cue (CS+) but never with a conditioned safety cue (CS-). The conditioned stimuli were circles of varying sizes. Fear-potentiated startle and US expectancy were measured during a conditioning phase and a generalization phase. The last paradigm was a counter-irritation paradigm (see further for detailed methods). Only the results of the counter-irritation paradigm are described here. A detailed description of the methods and results of the picture viewing paradigm and the rebreathing paradigm can be found elsewhere  or Hospital ZOL . Because of the large influence of circadian rhythms on physiological measures, this test session always took place from 2 to 5 pm. The test session consisted of a non-invasive baseline measurement of physiological parameters and four well-validated paradigms. In a first paradigm, the picture viewing paradigm, participants watched a positive, negative, and neutral picture series and were asked to rate their mood and physical symptoms after every picture series. In a second paradigm, a rebreathing paradigm, dyspnea perception was investigated. Dyspnea was induced with COlsewhere , 2018.Psychiatric comorbidity was assessed by the experimenter over the phone using the Dutch version of the MINI International Neuropsychiatric Interview 5.0.0., based on the DSM-IV , very slight – barely noticeable (5), very slight (10), slight (20), moderate (30), rather strong (40), strong (50), very strong (60–80), very very strong (90), and unbearable (100). Participants could click inside of the scale to indicate their pain rating, and press the spacebar to confirm their chosen rating. During pain rating, the exact numeric rating the participant had chosen was always presented on the screen next to the rating scale.Baseline HRV was derived from a 10-min ECG recording during which the participant was instructed to sit still and relax. Three disposable 8-mm Ag/AgCl electrodes were placed underneath the participant’s right and left clavicle and at the left lower ribs. The signal was sampled at 1000 Hz and fed into a Coulbourn V75-04 Bioamplifier . The ECG recording was visually inspected and processed offline with the ECG processing software ARTiiFACT , which wI don’t feel the stimulus; 1: I’m aware of the stimulus but it is not painful, it is merely a sensation; 2: The stimulus is not painful yet but it is unpleasant; 3: The stimulus is mildly painful up to 10: The stimulus is unbearably painful). The participants were encouraged to select the stimulus intensity scoring 8, meaning that the stimulus is painful and takes some effort to tolerate, but is tolerable for a few times. During the calibration procedure, the following intensity steps were used (until the participant indicated not wanting to go any higher): 1, 2, 4, 6, 8, 11, 14, 17, 20, 24, 28, and 32 mA.Electrocutaneous stimulation (80-ms train of 10 × 1 ms pulse) was delivered with a constant current stimulator . Two 8-mm Ag/AgCl electrodes filled with K-Y jelly were attached to the right ankle. The intensity of the electrical stimulation was determined individually with a calibration procedure, during which participants received electrocutaneous stimuli of increasing intensity. Participants were asked to rate each stimulus on a scale from 0 to 10 , participants were also asked to rate the painfulness of the CPAW on an equivalent rating scale.Average pain ratings in the baseline phase, counter-irritation phase and recovery phase were calculated for every participant.To investigate differences in EPM efficiency between patients and HC, a mixed model analysis was performed on the average pain ratings, with phase  and group  as fixed effects. Within this analysis, we tested specific hypotheses by comparing pain ratings in the different phases with each other in patients and HC separately.To investigate moderators of EPM efficiency within the patient group, several mixed model analyses were performed within the patient group, with phase and the moderator variable  as fixed effects in separate analyses. When appropriate, we performed follow-up tests by comparing pain ratings in the different phases with each other at different levels of the moderator.F- and p-values, hence the results are robust for changes in variance–covariance structure.The reported results are derived from mixed model analyses with an unstructured covariance matrix. Different more parsimonious mixed models were additionally run, with covariance structures that are conceivable given the design . These latter models did not improve model fit  compared to the models with an unstructured covariance matrix. Changing the covariance structure had very little impact on the p-values from specific hypothesis testing and follow-up tests were corrected for multiple testing with the stepdown Bonferroni method. All analyses were performed with SAS 9.4.All reported SD = 10.62; 71 women) and 41 HC  participated in the study. Data of the counter-irritation paradigm could not be used for 7 HC and 2 patients due to technical malfunctions. Data of 1 HC and 1 patient could not be used because they misunderstood the instructions. The final sample therefore consisted of 78 patients and 33 HC. Mean levels of NA, RMSSD, and perceived pain from the CPAW for patients and HC are presented in Table 1. Patients had higher levels of NA, but did not differ from HC with regards to RMSSD and perceived pain from the CPAW. Thirty-six patients (46.2%) fulfilled the criteria for current depressive episode as assessed by the MINI. Patients suffering from a depression had lower levels of RMSSD compared to patients not suffering from a comorbid depression . Fifteen patients (19.2%) were taking non-steroidal anti-inflammatory drugs (NSAID), 26 patients (33.3%) were taking opioids and 23 patients (29.5%) were taking paracetamol at the time of the test session. Forty-two patients (53.8%) were taking at least one type of analgesic, 36 patients (46.2%) were taking at least one type of antidepressant. Patients taking antidepressants had lower levels of RMSSD compared to patients who were not taking antidepressants , but RMSSD was not related to the use of analgesics. The intensity of the electrocutaneous stimuli used in the counter-irritation paradigm was determined individually during a calibration procedure. The median chosen intensity was, for both groups, 11 mA. An exact Wilcoxon rank sum test indicated that the distribution of the used intensity was equal in both groups .Eighty-one patients  nor by group . There was a trend for a group × phase interaction effect . The specific hypothesis test indicated that pain ratings in the baseline phase did not differ from pain ratings in the counter-irritation phase for patients  or HC . Pain ratings in the counter-irritation phase were significantly lower than pain ratings in the recovery phase for patients , but did not differ from each other for HC . Pain ratings in the recovery phase were higher than pain ratings in the baseline phase for patients , but did not differ from each other in HC , see Figure 1.Pain ratings during the counter-irritation paradigm overall did not differ by phase . Patients scoring higher on NA gave higher pain ratings overall , but this did not differ between phases . Therefore, follow-up analyses were not performed.When controlling for NA, the effect of phase on pain ratings was not significant . There was a trend for a main effect of depression on pain ratings during the counter-irritation paradigm  and a trend for a depression × phase interaction effect . Follow-up analyses indicated that electrocutaneous pain ratings in the baseline phase did not differ from electrocutaneous pain ratings in the counter-irritation phase for patients without  or with  a comorbid depression. Patients without comorbid depression had higher pain ratings in the recovery phase compared to the baseline phase  and the counter-irritation phase , while pain ratings did not differ between conditions in patients with comorbid depression , see Figure 2. An exact Wilcoxon rank sum test indicated that the chosen intensity of the electrocutaneous stimulus was equally distributed in patients with and patients without comorbid depression .When controlling for depression, the effect of phase on pain ratings was significant . RMSSD did not influence overall pain ratings during the counter-irritation paradigm , and there was no RMSSD × phase interaction effect . Therefore, follow-up analyses were not performed.When controlling for RMSSD, the effect of phase on pain ratings was not significant . To investigate if the pain experienced by the CPAW (cold pain) influenced the results of the counter-irritation paradigm, we performed a mixed model analysis on the entire sample with phase, group (patient vs. HC) and cold pain group (cold pain vs. no cold pain) as fixed effects and electrocutaneous pain ratings as the dependent variable. The main effect of condition , the main effect of cold pain group  and the main effect of group  on electrocutaneous pain ratings were not significant. There was, however, a trend for a group × condition interaction effect  and a significant condition × cold pain group interaction effect . The three-way interaction was not significant. . Follow-up tests indicated that electrocutaneous pain ratings did not differ between the baseline and counter-irritation phase, regardless of group and cold pain group . However, patients that experienced cold pain gave higher pain ratings in the recovery phase than in the counter-irritation phase , while patients who did not experience cold pain and HC did not , see Figure 3.It has been stated that the painfulness of the counter-irritation stimulus is not related to EPM magnitude, as long as the counter-irritation stimulus is noxious . A pain Z = 0.95, p = 0.34 for patients; Z = 1.18, p = 0.24 for HC). To investigate if the pain intensity elicited by the test stimulus influenced the results of the counter-irritation paradigm, we performed a mixed model analysis on the entire sample with phase, group (patient vs. HC) and test pain group (test stimulus painful vs. test stimulus not painful) as fixed effects and electrocutaneous pain ratings as the dependent variable. There were no significant main effects of condition  or group  on electrocutaneous pain ratings. There were significant group × condition  and condition × test pain group  interaction effects, but no significant three-way interaction effect . Follow-up tests indicated that electrocutaneous pain ratings did not differ between the baseline and counter-irritation phase, regardless of group and test pain group . However, patients who did not experience the test stimulus as painful gave higher pain ratings in the recovery phase than in the baseline phase , while patients who did experience the test stimulus as painful and HC did not , see Figure 4.To investigate if the pain experienced by the test stimulus (electrocutaneous stimuli) influenced the results of the counter-irritation paradigm, we performed a mixed model analysis on the entire sample with phase, group and test stimulus pain as fixed effects and electrocutaneous pain ratings as the dependent variable. It is recommended that the test stimulus has a subjective painfulness of around 40/100 . ParticiF2,108 = 0.03, p = 0.86). There were no significant interaction effects . Therefore, follow-up analyses were not performed.It has been shown that EPM efficiency declines with age, and that EPM efficiency is already smaller in middle-aged (40–55) individuals compared to young (20–35) individuals . Over 54F1,108 = 0.92, p = 0.34). There were no significant interaction effects . Therefore, follow-up analyses were not performed.It has been shown that EPM efficiency is reduced in conditions of mental stress . Since tF1,74 = 0.47, p = 0.49), and there was no analgesics × phase interaction effect . Therefore, follow-up analyses were not performed. Analgesic use did not influence overall pain ratings during the counter-irritation paradigm , and there was no analgesics × phase interaction effect . Therefore, follow-up analyses were not performed. Since there is evidence that the chronic use of opioids specifically can influence the perception of experimentally induced pain , and there was no opioids × phase interaction effect . Therefore, follow-up analyses were not performed.EPM efficiency might be influenced by the chronic intake of medication. Since a large number of patients were taking analgesics and/or antidepressants, we investigated the effect of analgesic use and antidepressant use on the results of the counter-irritation paradigm within the patient sample alone. Antidepressant use did not influence overall pain ratings during the counter-irritation paradigm , during (counter-irritation) and after (recovery) application of a CPAW. A larger reduction in pain ratings during counter-irritation (compared to pain ratings in the baseline phase) indicates more efficient EPM. In replication of previous studies, we expected that HC would have more efficient EPM than patients and that EPM efficiency within the patient group would be moderated by NA, the presence of a depression and by baseline RMSSD.In contrast to our expectations, neither patients nor HC experienced the electrocutaneous stimuli as less painful in the counter-irritation compared to the baseline phase. Thus, we were not able to replicate the counter-irritation effect in our sample, making it impossible to draw valid conclusions on differences in EPM efficiency between patients and controls and on moderators of EPM efficiency within the patient group. It is known that the counter-irritation effect is influenced by and dependent on several methodological factors . TherefoA first factor is the painfulness of the counter-irritation stimulus. Figures 3, 4). Most counter-irritation paradigms and conditioned pain modulation paradigms compare pain ratings during or after counter-irritation with pain ratings before counter-irritation (Some specific findings deserve further attention. While there was no difference in pain ratings for the electrocutaneous stimuli between the baseline phase and the counter-irritation phase, patients overall rated the electrocutaneous stimuli in the recovery phase as more painful than the electrocutaneous stimuli in the counter-irritation phase and the baseline phase. These results suggest some sort of “rebound”-effect in patients, where the removal of the counter-irritation stimulus causes a reinstatement of pain elicited by the electrocutaneous stimulus. Only patients without comorbid depression showed this reinstatement of pain. Although such a reinstatement is often found in studies using similar paradigms, it is generally found in HC following successful pain reduction in the counter-irritation phase , while iritation , with thritation  or similritation . Since iThere are a number of limitations to our study that might explain the absence of an overall counter-irritation effect in this study. First, the paradigm used was adapted from The aim of this study was to investigate individual differences in EPM in a sample of patients with fibromyalgia and/or CFS by means of a counter-irritation paradigm. We focused on NA, comorbid depression, and HRV in rest as possible moderators within the patients group. However, we did not manage to successfully create a counter-irritation effect in patients or HC. Therefore, no valid conclusions on the moderating effect of NA, depression and RMSSD within the patient group can be drawn from these results. Although the DNIC-mechanism is a well-described phenomenon and the counter-irritation paradigm is widely used as a measure of EPM-efficiency, our results suggests that the counter-irritation effect is not always replicable. This brings about the question if the current knowledge on EPM and its significance for chronic pain conditions might be narrowed by positive publication bias. In any case, the methodologies between different studies employing one form of the counter-irritation paradigm vary widely, and success/failure of the paradigm might depend on the modality, intensity and timing of the used stimuli, and on which outcome statistic and data-analysis is chosen for the interpretation of the results . CurrentMVDH was responsible for the data collection and data analysis. All authors contributed to the conception or design of the study, to the interpretation of the data, and to the drafting or revising of the manuscript. All authors have approved the final version of the manuscript. All authors agreed to be accountable for all aspects of the work.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.


Objective: To evaluate the effects of acupuncture branches on postpartum low back pain severity among the primiparous subjects visiting the selected educational centers affiliated to Shiraz University of Medical Sciences, Shiraz, Iran. Materials and methods: This clinical trial was conducted on 150 (each group of 50 people) cases in 2012. Cupping therapy was done every other day in four 15-20 minute sessions a week. Besides, acupressure was applied according to the circular model for 20 minutes. The patients filled out the short form McGill Pain Questionnaires. Then, the data were analyzed using the SPSS statistical software (v. 16) and repeated measurements and Chi-square tests.Results: In the cupping group, the mean difference of postpartum Low Back Pain intensity reached from 31.8 ± 10.8 before the intervention to 9.0 ± 6.7, 7.5 ± 6.6, and 4.1 ± 3.6 immediately, 24 hours, and 2 weeks after the intervention, respectively and the results of repeated measures ANOVA showed a significant difference between the three follow-up periods (p < 0.05). On the other hand, this measure reached from 31.1 ± 11.0 before the intervention to 22.1 ± 7.3, 16.2±6.0, and 11.7 ± 5.3 immediately, 24 hours, and 2 weeks after the intervention, respectively in the acupressure group.Conclusion: The study results showed that these modalities could sedate the pain. Therefore, they can be applied as efficient treatments for reducing the low back pain. Low back pain is a very common painful disorder in primary care. In general, 80% of people suffer from this pain at least once in their life and it recurs in 60% of the patients. The symptoms of the disorder are not related to any particular etiological or neurological causes in 85% of the cases and it seems that 23% of the patients suffer from pain for more than 12 weeks and have chronic conditions . GeneralThe present randomized clinical trial was conducted at Hafez Hospital of Shiraz University of Medical Sciences (SUMS), Shiraz, Iran in 2012. In this study, pain diagnosis was based on taking a medical history of the participants. According to the statistical consultation, using the sample size formula (=N3= 50)  and the Classification was performed as follows: A: cupping group, B: acupressure group and C: control group. Accordingly, ABC: 1, ACB: 2, BAC: 3, BCA: 4, CAB: 5, and CBA: 6. It should be noted that numbers 0, 7, and 9 were ignored. Sampling continues until the number of samples in the same complete. The inclusion criteria of the study were being between 18 and 40 years old, having at least middle school degrees, not having any overt and serious psycho-somatic diseases, such as vertebral fractures, herniated disk, acute inflammation, and deep vein thrombosis, living in Shiraz, being willing to participate in the research project and completing a consent form, and suffering from low back pain merely due to lordosis resulting from pregnancy and childbirth which was intensified by fetus weight and position or labor process in some mothers. Cupping therapy was performed every other day in four 15-20 minute sessions a week. Besides, acupressure was applied according to the circular model for 20 minutes. However, no interventional treatments were performed for the control group. The patients filled out the short form McGill Pain Questionnaires before and immediately, 24 hours, and 2 weeks after the treatments. This instrument is the most reliable measure of pain (particularly chronic and resistant pains) that allows the patients to choose the right words to express their perception of pain , but becThen, the data were analyzed using the SPSS statistical software (v. 16). Repeated measurements test with group and individual adjustment was used in order to compare the changes in mean and standard deviation of pain scores before and after the intervention. Chi-square test was also employed to investigate the demographic characteristics of the three study groups. All the statistical tests were performed considering alpha coefficient of 0.05 and confidence interval of 95%. The weak point of this study was that patients were aware of the causes and mechanisms of the interventions and the problem was intensified due to the lack of placebo. However, due to the nature of the procedure, this was out of the researcher's control.The study results revealed no significant difference between the three groups regarding the demographic characteristics; i.e., maternal age (p = 0.064), mother's age at marriage (p = 0.210), and mother's education level (p = 0.998) before the intervention. The average pain intensity was 31.8 ± 10.8, 31.1 ± 11.0, and 31.8 ± 9.8 in the cupping, acupressure, and control groups, respectively and the results of ANOVA revealed no significant difference between the intervention groups and the control group (p = 0.1) . ImmediaThe present study was the first clinical trial on the gynecologic diseases in Iran and the world. This study aimed to investigate the therapeutic effects of cupping, suction, and stimulation of different parts of the body by applying pressure on low back pain after delivery. According to the study results and short-form McGill Pain Questionnaire, the intensity of low back pain after delivery decreased from 10.8 ± 31.8 before the intervention to 9.0 ± 6.7, 7.5 ± 6.6, and 4.1 ± 3.6 immediately, 24 hours, and 2 weeks after the intervention, respectively in the cupping therapy group. In addition, the results of repeated measures ANOVA revealed a significant difference among the follow-up stages (p = 0.01). This significant decrease might be due to the physiological effects of cupping therapy which is based on stimulation or relaxation of the body through suction. Up to now, a lot of evidences have supported the use of dry cupping compared to conventional treatment methods for the patients suffering from low back, pelvic, and cancer pains .On the other hand, the intensity of low back pain in the acupressure group reduced from 31.1 ± 11.0 before the intervention to 22.1 ± 7.3, 16.2 ± 6.0, and 11.7 ± 5.3 immediately, 24 hours, and 2 weeks after the intervention, respectively which was significantly different in various follow-up stages. In fact, manipulation and stimulation of small, myelinated peripheral nerve fibers in the muscles using a needle or its substitute; i.e., pressure, send signals from the spinal cord to the midbrain and the pituitary axis eventually leading to release of Encephalin, Dinorphine, and Serotonin into the blood stream as well as the cerebrospinal fluid and reduction of pain . This meAccording to short-form McGill Pain Questionnaire, the mean of the sensory dimension of low back pain intensity decreased from 22.8 ± 7.9 before the intervention to 7.0 ± 5.5, 5.8 ± 5.4, and 3.2 ± 2.7 immediately, 24 hours, and 2 weeks after the intervention, respectively in the cupping therapy group and the differences were statistically significant. Based on the cultural effects of cupping therapy which offers a clear explanation about the cause and treatment of the disorder, the disease is hidden in the blood. When blood is accumulated at one point, the disease disappears and the patients feel that the disease is leaving their bodies . Of courIn the acupressure intervention group, on the other hand, the corresponding values were 22.5 ± 8.2, 16.4 ± 5.6, and 12.8 ± 6.1, respectively which were not statistically significant compared to those of the cupping therapy group. However, a significant difference was observed within the acupressure group 24 hours and 2 weeks after application of pressure compared to before the intervention. This might have resulted from the role of acupressure in releasing lactic acid and carbon monoxide accumulated in the body while muscles contraction which helps the patients’ satisfaction . On the In the cupping therapy group, the mean of the emotional dimension of low back pain intensity based on the short-form McGill Pain Questionnaire decreased from 9.0 ± 4.3 before the intervention to 2.1 ± 2.1, 1.7 ± 1.5, and 1.8 ± 1.2 immediately, 24 hours, and 2 weeks after the intervention, respectively and the difference among the follow-up stages was statistically significant. However, this value increased after 2 weeks compared to 24 hours after the intervention which might have resulted from the disruption of the relationship between the mothers and the researcher. In fact, the psychological effects of cupping therapy result from the sequential status of the treatment. Thus, the close relationship between the cupping therapist and the patients plays a critical role in the emotional dimension of pain .In the acupressure intervention group, the corresponding values were 8.9 ± 3.4, 5.6 ± 2.8, and 4.0 ± 2.4, respectively which were significantly different in comparison to those of the cupping therapy group. Nonetheless, a significant difference was observed in the acupressure intervention group 24 hours and 2 weeks after the intervention compared to before the intervention. In addition to the pain reduction mechanism of acupressure and increase of mothers’ tranquility, continuous presence of the researcher by the patients during the intervention as well as providing them with the necessary directions and following them up until two weeks after the delivery have been effective in improving the patients’ emotional status in perceiving the intensity of low back pain. Similar conditions were also observed in the study Kim et al (2011) conducted in order to determine the effect of cupping therapy on reduction of low back pain. That randomized clinical trial was performed on 21 patients in the cupping therapy group and 11 ones in the control group who had been suffering from low back pain for at least three months. The participants were randomly assigned to either the cupping therapy or the control group. The intervention group underwent cupping therapy on BL23, BL24, and BL25 points for 6 times in 2 weeks. On the other hand, the control group received exercise brochures and general recommendations. It should be mentioned that both groups were allowed to use acetaminophen. The study instruments included a 0-100 Numerical Rating Scale (NRS) for pain, McGill Pain Questionnaire for Pain Intensity (PPI), and Oswestry Disability Questionnaire (ODQ). Before the intervention, McGill Questionnaire showed the mean score of pain to be 43.2% in the cupping therapy and 91.1% in the control group and the difference was not statistically significant. After the intervention, however, the mean score of pain was reported as 2.1% and 7.1% in the cupping therapy and the control group, respectively and the difference was statistically significant (p < 0.01). In addition, acetaminophen consumption was significantly lower in the cupping therapy group during 4 weeks (p = 0.09). On the other hand, 6.5 and 8.1 points reduction was observed in the ODQ scores of the cupping therapy and control groups, respectively which was not statistically significant (p = 0.14). Overall, since the reported pain intensity had reduced for 30%, cupping therapy on BL23-25 points can be considered as an effective method in reducing the low back pain but the reason is unknown  carried out a randomized, controlled clinical trial in an orthopedic specialty hospital in Taiwan. In that study, 146 subjects who suffered from chronic low back pain were randomly divided into an acupressure (n = 69) and a physical therapy group (n = 77). A self-report in the form of short-form McGill questionnaire was obtained from the patients before and after the intervention. The study results revealed no significant difference between the two groups regarding the basic characteristics (p = 0.13) . Before In the same line, Yeh et al (2012) investigated the effect of auricular acupressure treatment on chronic low back pain in the U.S. The intensity of pain was measured using the short-form pain questionnaire after 7 days of intervention. The patients in the worst possible pain and moderate pain groups respectively reported 46% and 50% reduction in their pain intensity at the end of the intervention. Overall, the researchers concluded that acupressure could help treat the back pain through the body’s meridians .Considering the fact that cupping therapy has been widely used for treatment of low back and pelvic pain in Korea and the cupping therapist have mostly been female, the survival of cupping therapy may result from the societies’ social, cultural, and economic features.One other study supporting the basic principles is the randomized, controlled clinical trial performed by Yip et al (2004) in Hong Kong in order to assess the effect of stimulation of the pressure point with electrodes together with acupressure. One week after the treatment, the intervention group demonstrated 39% greater pain reduction on VAS compared to the control group (p = 0.0001) .In Germany, Lauche et al (2011) conducted a pilot study and investigated the effectiveness of dry cupping therapy as an old method for treatment of painful syndromes in the patients suffering from chronic neck pain. In that study, the patients’ sensorimotor threshold, self-evaluating scale of pain outcomes, and life quality were evaluated. The intervention group underwent cupping therapy for 5 times during 2 weeks. Consequently, the intervention group’s neck pain decreased every day and a significant difference was observed between the two groups’ reported pain after the intervention (p = 0.001) . TraditiOverall, the findings of the studies conducted on the issue support the use of traditional medicine in treatment of diseases and up to now, they have been accompanied by no severe complications to affect their efficiency and safety.Conclusion: The results of the present study showed that although the pain intensity decreased in both study groups, the reduction of pain intensity was significant in the cupping therapy group. Therefore, both cupping therapy and acupressure can be effective in reduction of postpartum low back pain in primiparous women.Apparently, placebo should be used in order to avoid bias. However, it was not employed in the current study due to the transparent nature of its performance. Thus, further clinical trials using placebos are needed to be conducted in order to determine the accuracy of the obtained results. Moreover, safety is of great importance in order to evaluate the efficiency. In wet cupping therapy, sterilization was not completely observed resulting in the risk of blood borne infectious diseases through contaminated instruments. However, this limitation cannot be attributed to the present study since it utilized dry cupping therapy.


During oxaliplatin chemotherapy administration via a peripheral vein, vascular pain requires changing of the intravenous infusion route on occasion. Vascular pain induced by anticancer drugs reduces the rate of patient continuation and completion of chemotherapy. Pain is presently appraised using subjective methods, such as the visual analog scale (VAS). However, because pain evaluation can vary depending on the physical state and mood of the patient at the time of assessment, it is desirable to evaluate pain objectively. PainVision PS-2100 (PV) is a medical device that was designed to objectively and quantitatively assess patient nociception and perception.The present study examined the correlation of subjective and objective assessment of oxaliplatin-induced vascular pain using VAS and PV, respectively.Vascular pain was assessed using both PV and VAS a total of 173 times for 58 colorectal cancer patients. Partial correlation analysis was performed to evaluate the relationship between PV and VAS. The mean PV and VAS scores were 44.5 (range: 0–596) and 24.8 (range: 0–100), respectively. The partial correlation coefficient was 0.408 (p < 0.0001).A strong correlation was not observed between the results, and a weak correlation was observed between VAS and PV scores. Objective evaluation of oxaliplatin-induced vascular pain will be required to help patients overcome vascular pain. FOLFIRI (irinotecan with folinic acid and fluorouracil) and FOLFOX  therapies for colorectal cancer (CRC) require the use of central venous (CV) ports. Recently developed therapies combining capecitabine plus oxaliplatin (XELOX) allow for chemotherapy via a peripheral vein without CV port .Patients with histologically confirmed metastatic CRC who had not received chemotherapy or who had completed adjuvant chemotherapy during the last 6 months were enrolled in this study. Patients with a poor mental health that prevented understanding of the concepts of PV and VAS were excluded. Patients were also excluded if they had experienced any musculoskeletal pain or peripheral sensory neuropathy prior to chemotherapy that may have disrupted the quantitative measurement of pain. Written informed consent was obtained from all patients.2 oxaliplatin on day 1 plus 2000 mg/m2 capecitabine on days 1–14, repeated every 3 weeks) or XELOX therapy  ” on the left edge and “100 (worst pain imaginable)” on the right edge  value of <0.05 was considered statistically significant.Data were analyzed using SAS software ver. 9.3 . To evaluate the reliability of the device in terms of internal consistency, we assessed the quantitative pain degree score twice. Data are reported as the mean ± standard deviation, median (25–75% interquartile range), or number (percentage) of participants. Partial correlation analysis was carried out to estimate the relationship between VAS and PV after adjusting for subject and sex. In other words, the correlation coefficient between VAS and PV was calculated using residual values of the mixed-effects model including sex as a fixed effect and subject as a random effect. A probability . The final cohort included 18 women and 40 men . The characteristics of the study patients are shown in Table p < 0.0001), 0.41 (p < 0.0001), and 0.45 (p < 0.0001), respectively  and 44.5 (range: 0–596), respectively. The partial correlation coefficients with no adjustment, after adjusting for subject and sex, and after exclusion of outliers (one patient) were 0.49  considering the paired sampling, different inter-individual variations between measures and some covariates have been proposed (Kiyomi et al. To the best of our knowledge, there is no report that has quantified oxaliplatin-induced VP using electrical stimulation. One limitation of this study was using only VAS as a subjective evaluation and not allowing adequate VP assessment. Accordingly, the Neuropathic Pain Questionnaire, Leeds Assessment of Neuropathic Symptoms, and Signs scale and Douleur Neuropathique en 4 Questions should also be compared to confirm the current findings. We think that the drug effects for oxaliplatin-induced VP should be evaluated objectively.Although both assessment methods evaluated the same phenomenon, a strong correlation was not observed between the results of each assessment method, and only a weak correlation was observed between PV and VAS. These results suggest that because PV and VAS each measure different factors, both may be needed to adequately evaluate oxaliplatin-induced VP with the aim of aiding treatment. These findings are expected to help with the improvement of VP through the usage of an objective assessment method and to support future clinical trials associated with VP caused by oxaliplatin.


Central poststroke pain (CPSP) caused by sensory dysfunction of central origin is a disabling condition that significantly affects the quality of life of stroke patients.  The aim of this study is to determine the clinical profiles and pattern of CPSP among stroke patients in Kano, Nigeria.  The study was a cross-sectional design involving stroke survivors who were ≥18 years old and with no significant cognitive impairment approved by the Research Ethics Committee of Aminu Kano Teaching Hospital. Participants were assessed using diagnostic criteria form, the douleur neuropathique 4 questions (DN4 questionnaire), and Leeds assessment of neuropathic symptoms and signs (LANNS).  A total of 120 stroke patients participated in the study, in which 6 (5%) were diagnosed with CPSP occurring within the first 3 months in 50% of the participants. The pain characteristics were mainly moderate (83.3%), burning (62.5%), and continuously experienced (66.7%). The frequently affected parts were extremities or occurring as hemisyndrome.  Prevalence of CPSP following stroke is low. The clinical features are variable and can occur at a varied time and different intensities and locations. However, it majorly occurs within the first few months post stroke. Stroke is now an important public health concern. It is classically characterized as a neurological deficit attributed to an acute focal injury of the central nervous system (CNS) by a vascular cause, including cerebral infarction, intracerebral hemorrhage (ICH), and subarachnoid hemorrhage (SAH) . When stCentral poststroke pain (CPSP) is a constant or intermittent pain reported by patients after stroke that is usually associated with sensory abnormalities such as decreased perception of harmful and sharp stimuli . The symAlthough, there remain some mysteries as to the pathophysiology of CPSP, it is believed to be caused by stroke in the region of the thalamus  and extrThe study was a cross-sectional  study approved by the Research Ethics Committee of Kano State Hospitals Management Board which caters for all the hospitals under the jurisdiction of the state government. The population of the study was patients with stroke attending outpatient physiotherapy departments at Murtala Muhammad Specialists Hospital (MMSH) and Muhammad Abdullahi Wase Specialist Hospital (MAWSH) in Kano. Participants were sampled using convenience sampling technique using the following inclusion criteria: adult stroke patients who are 18 years of age or above and patients with no significant cognitive impairment  >17).The nature and procedure of the study were explained to the participants, and those who signed the informed consent form were interviewed. Information about demographic characteristics of the study participants, stroke condition, and pain were obtained and documented in diagnostic criteria form. The diagnostic criteria form used by Klit and his colleagues were used to assess for participants who are suspected to have CPSP . The criOther instruments used in the study include pain assessment record form for collecting the details on the pain characteristics such as onset, description, abnormal sensation and its description, brush for testing dynamic allodynia, toothpick used for testing pinprick hyperalgesia, test tube for heat (40°) and cold (15°) sensation, and alcohol for sterilization. Pinprick and thermal (heat and cold) sensations were tested at the patients' pain location at the interval of 5 minutes each. Additionally, the douleur neuropathique 4 questions (DN4 questionnaire) and Leeds assessment of neuropathic symptoms and signs (LANNS) were also used.The DN4 questionnaire is a 4-item questionnaire developed by Bouhassira and colleagues . It is aU test. All analyses were carried out using SPSS version 16.The demographic characteristics of the study participants and their CPSP clinical profiles were analyzed using descriptive statistics of mean, frequency, and percentage. The gender difference in the clinical profiles was analyzed using Mann–Whitney A total of 124 patients were contacted for the study; out of this, 4 refused to participate. One hundred and twenty patients were interviewed in which 20 were suspected to be having CPSP. After sensory and clinical examinations, 6 patients were diagnosed with CPSP corresponding to an incidence of CPSP of 5% in the study population.Out of the 120 stroke patients assessed, 57 (47.5%) were male and 63 (52.5%) were female with mean age of 55.8 ± 10.9. For the participants diagnosed with CPSP, 4 (66.7%) were male and 2 (33.3%) were female with mean age of 59.3 ± 9.4 (47–73). All of the participants with CPSP had ischemic stroke, and one had recurrence of the stroke within 1 year. See The average period of the onset of stroke to the time of the study was 11 ± 5.7 months, and average period of pain onset from stroke onset was 4.2 ± 4.3 months. One (16.7%) of the participants started experiencing chronic pain immediately after stroke; in 3 of the participants (50%), the pain onset was within 3 months after onset of stroke; and in 2 of the participants (33.3%), the pain was after 6 months. Majority of the participants were experiencing moderate pain (83.3%) and the rest, severe. Four (66.7%) of the participants reported the pain to be continuous and had experienced change in pain from its onset. Burning sensation (62.5%) is the most reported pain descriptor followed by electric shock. At least 2 (33.3%) of the participants had more than one pain descriptor, and 1 (16.7%) had 3 pain descriptors. All the participants had 1 or 2 other associated poststoke pains, 50% had painful shoulder, and 20% had spasticity related pain. See The main aggravating factors reported were psychological stress, contact to cold/heat, and movement of the limb. The average DN4 questionnaire and LANNS scores were 5.5 ± 1.0 and 16.2 ± 2.1, respectively, indicating that neuropathic mechanisms are contributing or responsible to the patient symptoms. Pain location and distribution were multifocal (90.9%) in almost all the participants. The main sensory abnormalities were tactile allodynia (35.7%) and pinprick hyperalgesia (35.7%). About 33% of the participants had 3 sensory abnormalities, and all had more than one sensory abnormality as shown in U test revealed that there was no significant difference (p > 0.05). See For the difference in the clinical characteristics between male and female participants diagnosed with CPSPS, Mann–Whitney The aim of this study was to find out the profiles of CPSP in Kano, Nigeria. The result of the study showed a CPSP prevalence of 5% which is within the range of 1–12% reported in the literature by Klit and colleagues and Kong and colleagues , 20–22. The result also showed that the duration of CPSP onset varies greatly. In the present study, about 50% of the participants had pain onset within the first three months and 16.7% immediately after stroke. In consistent with our findings, previously, it was reported that CPSP occurs between 3 and 6 months post stroke . HoweverOccurrence of CPSP may depend on gender. In this study, CPSP is more prevalent in men than in women. However, it has been argued that gender is not a reliable predictor of CPSP as it may be more prevalent in either men or women . AdditioCentral poststroke pain (CPSP) can occur alongside other pain symptoms, though it is difficult to distinguish between CPSP with other pain syndromes . In thisPoststroke central pain can have psychological impact on the patients, reduces sleep quality, and interferes with activities of daily living. Previously, pain in stroke patients was reported to result in sleep disturbance and general well-being ; and paiPrevalence of CPSP following stroke is low. The clinical features are variable and can occur at varied times and different intensities and locations. However, it majorly occurs within the first few months post stroke. Therefore, clinicians are advised to be on the watch out for its signs and symptoms in order to help forestall any possible burden it will impose on the patients.


N = 1,868) and, second, the characterization of BTP in these patients (N = 295). Data was collected on presence of BTP, type and location of pain, treatment, compliance, and patient satisfaction. We found a prevalence of BTP in patients with CLBP of 37.5% (95% CI: 35.3%–39.7%), similar in men and women. 75% of the patients were older than 50 years. The preferred drug of patients who control BTP with opioids is fentanyl (78.3%) and its most common form of administration is nasal (53.2%). Therapeutic compliance was high and 46.3% of patients considered the control of their BTP very satisfactory. Our study showed that BTP is common in patients with CLBP and that current treatments seem adequate.Chronic low back pain (CLBP) is highly prevalent in industrialized countries, where it is one of the main causes of disability. Patients with CLBP in treatment with opioids often experience episodes of breakthrough pain (BTP), but data on prevalence and treatment preferences are scarce. The objectives of this study were, first, the evaluation of the prevalence of BTP in patients with CLBP in the South of Spain ( Chronic low back pain (CLBP) is defined as localized pain between the lower limit of the ribs and the lower limit of the buttocks that lasts for more than 12 weeks. In CLBP the intensity of pain varies depending on postures and physical activity and is usually accompanied by severe limitation of the movement . BTP epiThe prevalence of BTP in cancer patients has been widely described and ranges from 33% to 89% , 6. In SCLBP prevalence data ranging from 13% to 50% have been reported , and in This is an observational, multicenter, cross-sectional epidemiological study of BTP in patients with CLBP. The study was conducted in the Pain Units of 20 hospitals in the South of Spain  between July and December of 2015. The main objective was to assess the prevalence of BTP in patients with CLBP and the secondary objectives were to characterize BTP based on etiology, pathology, and other clinical characteristics  and to evaluate the prevalence of each of the different causes of pain.The selection criteria for the study of prevalence were (a) age of patients >18 years; (b) patients with chronic pain secondary to opioid-controlled CLBP; (c) patients with adequate oral and written comprehension; and (d) informed consent of the patient.In this study, cross-sectional data collection was carried out for 3 months in each of 20 participating centers, all large hospitals throughout the Autonomous Region of Andalucia and Melilla. The population of this area of Spain was 8.388 million in 2016. The hospitals participating in the study were the Carlos Haya Hospital ; Poniente H. ; Virgen del Rocío H. ; Ciudad de Jaén H. ; Comarcal Melilla H. ; Virgen de la Victoria H. ; Puerto Real University H. ; SAS de Jerez H. ; Guadix H. ; Reina Sofía H. ; Nuestra Señora de Valme H. ; Baza H. ; Puerta del Mar H. ; Torrecárdenas H. ; and Virgen Macarena University H. . 1,868 patients were surveyed in the study of BTP prevalence.The prevalence study included all the data recorded by the researchers in the prevalence sheets during the established period. In the study of the secondary objectives, all the patients that met the selection criteria established in the protocol (295 patients) were included. Twelve patients were excluded from the analysis of the characterization of BTP because they did not meet the selection criteria.Informed consent was obtained from all individual participants included in the study. All procedures performed were conducted in accordance with the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards. The study was approved by the Ethics Coordinating Committee for Biomedical Research of Andalucia on May 4, 2015 (study code: ADD-DOL-2015-1).In the prevalence study the following variables were collected: presence of BTP (yes/no), sex, and age. The prevalence of BTP was calculated as the number of patients with BTP over the total number of patients surveyed. Secondary variables collected included types of BTP , number of BTP episodes in the last month, origin, cause, location, average time until BTP relief, average duration of episodes and baseline, and rescue treatments.Each investigator identified, over a period of 3 months, patients with CLBP on treatment with opioids who came to the Pain Unit. The patients were specifically asked about the presence of BTP. Patients included in the study were the first two patients of each day who met the inclusion criteria and gave their informed consent. During a single visit the researcher collected the data and variables of the study. Data collection was performed for 3 months in each participating center. Given their observational nature, the data were obtained from the patient's medical record and/or directly from the patient and according to the physician's usual clinical practice. Pain intensity of patients with BTP was assessed using a visual analogue scale (VAS). Data collection was done using Data Collection Notebooks on paper. The data was stored in a relational database on a MySQL server. The database was protected by an SSL security certificate for the correct encryption of the data. The database was endowed with security margins and internal consistency rules to avoid the entry of incorrect data or of anomalous or inconsistent values.t-test.All patients who fulfilled the selection criteria and gave their informed consent were included in the statistical analysis of the study. The prevalence of BTP with its respective 95% confidence interval was calculated as the percentage of subjects who presented BTP among the number of patients with opioid-controlled CLBP collected by each investigator in the frequency sheet of patients over 3 months. This prevalence was also adjusted by age and sex group. Given the descriptive nature of the study, the statistical methodology used was based mainly on an exploratory analysis of the data by means of the calculation of descriptive parameters. Categorical variables were presented as absolute frequencies and relative frequencies. The possible association between the intensity of BTP according to the VAS scale and the type of BTP  was analyzed by the Student This cross-sectional observational study analyzed the prevalence of BTP in patients with CLBP who visited the Pain Unit of large hospitals in Andalucia and Melilla (Spain). A total of 1,868 patients were included, of whom 25% were under 50 years of age, 50% were between 50 and 71 years old, and 25% were older than 71 years. 36.1% of the patients included in the prevalence study were men and 63.9% were women. In the study of BTP characterization 295 patients were included and the mean age was 61.5 years (45.1% men and 54.9% women).p value = 0.178, Fisher's exact test) and age .We determined that the prevalence of BTP in patients with CLBP is 37.5% (95% CI: 35.3% −39.7%) in this population. The prevalence in men and women was similar, 39.6% and 36.4%, respectively. There were no statistically significant differences between the presence or absence of BTP as a function of sex  or low back and lower limbs (34.2%) . The aveWith regard to the frequency and duration of the BTP, 59.1% of the patients surveyed had 10 or more episodes of BTP in the month prior to data collection. The duration of seizures was less than 45 minutes in 78.7% of patients; time to pain relief was less than 15 minutes in 66.5% of cases, and 21.8% of patients suffered more than 5 daily crises .To treat chronic baseline pain (CLBP), 100.0% of patients used opioids and 50.5% were also medicated with nonsteroidal anti-inflammatory drugs . The mosWith regard to the treatment of BTP, 81.4% of the patients used opioids, mainly fentanyl (78.3%) and tramadol (12.9%) . The preCompliance for both CLBP and BTP was always high and above 90%. In the case of CLBP the medication was taken “generally” or “always” by 98.3% of the patients; in the case of treatment of BTP the “generally” or “always” responses were given by 91.2% of the patients . The mosRegarding the evaluation of the degree of satisfaction with the treatment, the “very satisfactory” response was superior to 40% for both the treatment of basic pain and that of BTP, being slightly higher in the latter (46.3%). However, the response was “somewhat unsatisfactory” or “very unsatisfactory” in 12.4% of the patients for the treatment of CLBP and of 17.3% for the treatment of BTP . Our resThe main objective of this epidemiological study was to determine the prevalence of breakthrough pain (BTP) associated with chronic low back pain (CLBP) in patients who visited the Pain Units of hospitals in Andalucia and Melilla, in the South of Spain. We have determined that the prevalence of this type of pain is 37.5% (95% CI: 35.3%–39.7%). In addition, we have characterized these types of pain and their treatment in the region. This study has allowed us to know and quantify the degree of compliance and satisfaction of patients with regard to pain treatments, thus enabling future therapeutic interventions and better management of the problem.Opioids are useful drugs that can be used in the treatment of CLBP, although careful dosage and monitoring of adverse effects such as constipation, nausea, pruritus, dizziness, drowsiness, and tolerance should be monitored . NormallDespite their usefulness, the benefits and risks of opioids for patients with chronic pain have been a matter of debate, and specially their administration in the management of BTP. An adequate assessment of BTP should include frequency and duration of episodes, intensity and type of pain, precipitating factors, prior medication, and the effectiveness of rescue therapy. Clues about patterns of BTP in specific patients can be obtained from the patient record and even better from a “pain diary” in which the patient records the episode immediately . In our The limitations of the study are those derived from the design of the study, as it is a cross-sectional analysis where the frequency of patients with BTP associated with CLBP who were referred to the Pain Units may not be representative of the general population. This would occur if only certain patients and not all those with CLBP and/or BTP come to these units. Also, some of the parameters analyzed are subject to the effects of patient self-report, lack of coded diagnosis, and the evaluation of comorbidities. Additionally, the study was geographically restricted to certain centers of the Autonomous Communities of Andalucia and Melilla, and extrapolation of the results to the national population could be problematic.In this study we estimated the prevalence of BTP in the population visiting the Pain Units of hospitals in Andalucia and Melilla. Epidemiological data on BTP has allowed us to know the preferred treatments and the level of satisfaction of the patients. These parameters will undoubtedly help in the assessment of pain management in this group of patients and the possible improvement of future therapeutic interventions.


Spinal epidural abscess (SEA) is an uncommon but serious condition with significant morbidity and mortality. The prognosis of SEA is highly dependent on the timeliness of its diagnosis before neurological deficits develop. Unfortunately, often due to its nonspecific presentation, such as back pain, the diagnosis of SEA may be delayed in up to 75% of cases. Although many risk factors for SEA can be found in the published literature, their utility is limited by their frequent lack of objective evidence, numerousness, and absence in a significant proportion of cases. In this review, we call for a more discriminate evidence-based use of the term “risk factor” when discussing SEA and explore several approaches to its earlier diagnosis, including a simple algorithm based on its pathophysiology and serum C-reactive protein or erythrocyte sedimentation rate. Since its original postmortem description more than 250 years ago by Giovanni Morgagni, spinal epidural abscess (SEA) has often evaded timely diagnosis, with up to 75% of cases misdiagnosed on their initial healthcare encounter , 2. SuchAlthough SEA is uncommon, its incidence is rising. From 1975 to 1998, for example, the incidence of SEA rose from 0.2–1.2 to 2.5–3.0 cases per 10,000 hospital admissions . HeightePublished risk factors for SEA are numerous and include diabetes mellitus (DM), intravenous drug use (IVDU), alcohol abuse, infection with human immunodeficiency virus (HIV), degenerative joint disease, recent trauma or surgery, and the presence of spinal stimulators or catheters , 7–9. LoFirst, published risk factors or predisposing conditions for SEA are often derived from case reports, small case series, and literature reviews, which often fail to distinguish preexisting or potentially causative factors from coexisting conditions that may have very little role in the causation of SEA –15. ThisAnother limitation of the current risk factors is that formal studies to elucidate their independent association with SEA through statistical analyses have often involved a relatively small number of patients with contradictory results. For example, in a case-control study of patients admitted to a rehabilitation facility following SEA or spinal trauma, those with SEA were more likely to have used IV drugs but were not more likely to have DM or a history of alcohol abuse . Another S. aureus bacteremia, including DM, hemodialysis, HIV infection, heart disease, cancer, alcohol abuse, IVDU, COPD, and soft tissue infections [The sheer number of published risk factors also limits their clinical utility in the diagnosis of SEA. Some papers report as many as 50 “risk factors and sources of infection,” which often reflect common comorbidities or conditions often associated withfections , 25, 26.fections –29.SEA develops when microorganisms gain access to the epidural space via hematogenous spread from a distant source such as skin or respiratory or urinary tract; from contiguous foci of infection such as the psoas muscle or vertebra; or by direct inoculation through spinal instrumentation, injection, or catheter placement . Of thesAnother potential route of hematogenous infection is the pelvic cavity's venous drainage system, which connects with those of the spine and cranium via the spinal veins and forms Batson's plexus . This vaAlthough neurological deficits caused by SEA are often attributed to its direct compression on the spinal cord resulting in ischemia and injury , local c Staphylococcus aureus accounts for the majority of cases (60%–90%) with methicillin-resistant S. aureus (MRSA) accounting for an increasing number [ Escherichia coli often causes SEA in patients with UTI, while Pseudomonas aeruginosa may be the culprit in the setting of IVDU. Other pathogens such as mycobacteria, including Mycobacterium tuberculosis, tend to target immunosuppressed patients, while staphylococcal species other than S. aureus and fungi such as Candida species are often associated with spinal instrumentation or injection. SEA caused by an environmental fungus, Exserohilum rostratum, was recently reported in a multistate outbreak involving contaminated corticosteroid injections [Although SEA may be caused by a countless number of organisms,g number , 35–37. jections .Back pain is the most common presenting symptom of SEA, occurring in 70% to 100% of patients , 27, 39.Leukocytosis has been reported in 60% to 80% of patients presenting with SEA , 15. SerGadolinium-enhanced MRI is the radiographic test of choice for the detection of SEA with greater than 90% sensitivity and specificity , 3. Some S. aureus, from blood cultures. Lumbar puncture should be avoided in patients with suspected SEA due to the risk of spread of infection into the subarachnoid space [Once SEA is suspected radiographically, direct sampling of the infected fluid or tissue via image-guided biopsy should be performed to help confirm the diagnosis and direct antimicrobial therapy . In someid space .Antibiotics should be administered as soon as cultures from blood and other possible sources of infection have been obtained . AntimicIn addition to antimicrobial therapy, prompt surgery is indicated in most cases of SEA , 46, 47. M. tuberculosis-associated SEA should receive 6 months to 1 year of appropriate therapy . Whenever possible, infected indwelling spinal hardware  should be removed. Close monitoring for signs and symptoms of relapse after completion of antimicrobial therapy is essential in the management of SEA. Of note, one study found a treatment failure rate of 28% in patients with SEA caused by MRSA [Recommendations for the duration of antibiotic therapy vary widely from 4 weeks to 16 weeks depending on many factors, including comorbidities and concurrent presence of vertebral osteomyelitis . Althoug by MRSA .The outcome of SEA is often assessed based on mortality and recovery from neurological deficits . AlthougAbout one-third of survivors may have a poor neurological outcome often due to diagnostic delays . In factA major obstacle to the timely diagnosis of SEA is the nonspecificity of its signs and symptoms. In addition, as previously discussed, for the clinician evaluating a patient with severe back pain, the utility of published risk factors is limited due to their uncertain role in SEA causation, seemingly countless number, and absence in a significant proportion of patients who are ultimately diagnosed with SEA.Only a few studies have examined specific strategies for reducing delays in the diagnosis of SEA. A single-center study of routine MRI screening in emergency room patients suspected of having SEA yielded a diagnosis of SEA in less than 7% of patients  despite Another single-center study evaluated the impact of a decision guide on diagnostic delays of SEA in patients presenting to an ED with back pain . One or Another potential strategy for early detection of SEA consists of obtaining MRI in all patients with severe back pain. However, the feasibility and cost-effectiveness of this approach may be questioned in the current era of stewardship of healthcare resources . S. aureus bacteremia, contiguous focus of infection, and spinal injection/instrumentation). Accordingly, we recommend that patients with severe back pain and progressive neurological deficits undergo emergent MRI, or a CT if MRI is contraindicated. In the absence of progressive neurological deficits, those with recent S. aureus bacteremia or spinal injection/instrumentation should undergo urgent (within 24 h) MRI. In all other patients, ESR and CRP should be obtained, and if either is elevated, MRI should be considered, with its timing contingent upon the overall assessment of the patient, severity of pain, and the likelihood of noninfectious explanations for the back pain. If both ESR and CRP are normal, SEA would be much less likely and further workup for noninfectious causes may be pursued as appropriate.We propose an alternative strategy in the evaluation of patients with severe back pain which uses a simple algorithm . This al S. aureus), routine examination for spinal tenderness should be considered. This strategy is not dissimilar to searching for signs of endocarditis, such as new cardiac murmurs or embolic lesions, in patients with S. aureus bacteremia [We further suggest that, in patients without back pain but at high risk of SEA because of a recent bacteremic illness (particularly caused bycteremia . Of notecteremia .SEA is an uncommon but potentially devastating condition that continues to challenge the diagnostic skills of many clinicians. Reliance on published risk factors to help reduce diagnostic delays in SEA is limited by their seemingly countless number and their absence in a significant proportion of patients. More practical and feasible approaches to earlier diagnosis of SEA are sorely needed.


Chronic debilitating pain is a rare but significant cause of postoperative morbidity after inguinal surgery. Such pain is usually of neuropathic origin and frequently caused by intraoperative nerve damage. In this retrospective matched-pair study we analysed results of a minimal-invasive approach to neurectomy on quality of life and pain relief.From March 2010 to January 2012, 9 patients developing chronic neuropathic pain after inguinal hernia repair (8 patients) or open appendicectomy (one patient) were operated using a laparoscopic transabdominal approach in our department. Clinical examinations and specific questionnaires on pain and quality of life  were completed 6 months to 3 years after neurectomy. Every patient was matched with one patient without chronic pain.Seven of nine patients had severe or very severe pain before neurectomy, two had mild pain but refused a conservative treatment. Four patients were free of pain after neurectomy, three described an improved pain status, whereas two did not observe any change in pain. Within a follow-up period of 14,3 months, no deterioration of pain or other complications were observed. Patients who underwent neurectomy had significantly lower quality of life compared to the control group. No postoperative complications were observed.Laparoscopic transabdominal neurectomy represents a possible surgical approach in treating patients with chronic disabling postoperative groin pain requiring surgery. This technique was feasible, safe, and effective in our series to relieve chronic debilitating pain in the majority of our patients with comparable results to other published approaches. Chronic groin neuralgia is a well-known complication of operations involving a transverse incision of the right lower abdominal wall and occurs in approximately 0,5–6% of the cases postoperatively . InguinaNociceptive pain evolves as a result of tissue reaction to the inflammatory process caused by the operation, mesh related fibrosis or post-operative fibrosis . NeuropaStulz and Pfeiffer described surgery in 1982 as an option for treating nerve-associated pain . They peThe surgical approach for neurectomy still remains a controversial issue. The traditional standard approach is a two-staged approach: anteriorly to the ilioinguinal and iliohypogastric nerves and from the flank to the lateral femoral cutaneous and genitofemoral nerve . SurgeryIn this study we evaluated a transabdominal laparoscopic approach for accessing the retroperitoneal space for neurectomy. To our best knowledge, this is the first study to evaluate the impact of surgical therapy on chronic neuropathic pain in a series of patients using this surgical approach and evaluating the quality of life.We identified all nine patients who had developed chronic groin pain after operations of the right lower abdomen and had undergone a laparoscopic transabdominal retroperitoneal neurectomy (LTRN) in our department between March 2010 and January 2012. The clinical records of those patients were retrospectively evaluated. Patient characteristics are listed on Table Before LTRN  clinical examination by a specialized hernia surgeon and consultant (J.W.) had been performed in all patients in order to exclude a recurrent hernia. Pubic osteitis, orthopaedic pain syndromes, and other pathologies had been clinically or sonographically ruled out. LTRN had been indicated as a tailored decision combining clinical findings and respecting individual patient preferences. The neurectomy was performed using a transabdominal laparoscopic approach and is described in detail below. All resected nerves were histologically examined.Ethic approval was granted from our institutional ethics committee prior to the study. Patients agreed in an informed consent their participation to this study as well as the scientific use of their data.Identified neurectomy patients were invited by phone for a consultation and follow-up examination including a clinical examination. After the clinical examination, all patients were asked to fill out 3 questionnaires: The German version of the self-administered quality of life questionnaire (SF-36) , a validThrough the second clinical examination, recurrent hernia or other confusing painful groin pathologies were ruled out. A circumstantial neurological examination was also performed in order to reveal regional sensoric defects.Freyhagen et al.  developeThe SF 36  was deveA matched patient group for comparisons of generic quality of life data and neuropathic pain status was constructed using our clinical database records. These patients had undergone similar primary surgery without developing chronic postoperative pain, and were matched according to age, gender, primary operation, and date of the primary operation . Identified patients of the matched control group were contacted by telephone and requested to fill out the same three questionnaires, which were sent by mail.A 45-degree vision camera was inserted through a 10 mm trocar using a horizontal infraumbilical incision. Two further 5 mm incisions were performed. The sigmoid colon or caecum and ascending colon were mobilised. The ureter and the testicular vein were identified and preserved. The psoas muscle was visualized and any attachments were carefully removed in order to be able to identify the ilioinguinal and iliohypogastric nerve. These nerves were identified after penetrating the psoas muscle, while travelling on the quadratus lumborum muscle to the lateral abdominal wall. Depending on the patient’s symptoms, a triple-nerve neurectomy of the ilioinguinal, iliohypogastric, and genitofemoral nerve was not routinely performed. We selectively resected those nerves, the innervation region of which corresponded to our clinical symptoms and the localization of the pain. The genitofemoral nerve was resected in case of pain in the genital region, the ilioinguinal nerve in case of pain in the proximal, medial part of the upper thigh. The lateral femoral cutaneous nerve was resected in case of pain in the lateral upper thigh. In cases of overlapping in the proximal thigh we resected both the ilioinguinal and the lateral femoral cutaneous. We did not have any patients with pain directly at the old incision scar corresponding to a possible damage of the iliohypogastric nerve. The genitofemoral nerve was identified on the psoas muscle, lateral and caudal to the ilioinguinal nerve, before it’s splitting. The ends were electrocoagulated in order to prevent the formation of traumatic neuroma, and buried into the internal oblique muscle. Lateral to the genitofemoral nerve we identified the thinner lateral femoral cutaneous nerve.Sum score calculation and transformation of the quality of life questionnaire SF 36 was performed according to the German handbook of interpretation by Bullinger .p < 0.05.Descriptive statistics and exploratory association as well as group comparison analyses were performed with StatXact from Cytel Studios version 9.0  and SAS version 9.2 . The level of significance was set at p = 0.955). Patient 3 had a Lotheissen-Mc Vay operation and was matched with a Shouldice operation. Patient 4 had undergone an anterior herniotomy without mesh and was also matched with a Shouldice operation (Table The mean age of the LTRN- group was 57.1 years (SD 11.8) and the median 60 years . The mean interval between neurectomy and follow up was 14.3 months (SD 7.5) and the median 14 (range 5–26 months).Patients 3,4,5,6 and 8 had urologic comorbidities and Patient 2 had orthopedic comorbidities. The other patients did not have a relevant medical history.p = 0.264).The longitudinal development in the pain status of all patients from just before the primary operation till the end of the follow-up period was acquired using the questionnaire of Loos . Pain stp = 0.0004).Seven Patients from the LTRN- group had severe or very severe pain after the primary operation and two had mild pain. Eight patients from the control group had mild pain or no pain and only one described moderate pain. The level of pain after the primary operation between the two groups was statistically significant .Concerning the complication frequency of the primary operation in the LTRN- group, 3 patients had no complications, 3 had skin numbness, 2 had numbness with hypersensitivity and 1 had numbness, hypersensitivity, and postoperative bleeding which was conservatively treated. In the control group, 5 patients had no complications, 1 developed a wound infection, 2 numbness, and 1 patient developed a bulge . From the four patients with pain during sex, two were completely free of pain after the neurectomy, one described an improvement in the pain status and the last one didn’t notice any change.According to the adapted Loos-questionnaire, 4 patients from the LTRN- group described painful events during sex or orgasm before the neurectomy, whereas only one patient from the control group had such complaints . One rated it as excellent, 3 as good, 2 as moderate and 3 as bad. One patient rated the operation as bad, despite describing a clear improvement in his pain status. All patients were asked if they would decide to do the neurectomy when retrospectively knowing the result. Five answered yes, one answered no, and three were not sure.Comparing the pain status before and after neurectomy, seven patients described a remission of pain and two a persistence of the symptoms without deterioration of the pain. Two patients who described an improvement of their pain status were not sure if they would undergo the neurectomy again Table . One patConcerning the sensory status of the lower abdominal inguinal region and inner thigh after neurectomy, one patient had normal sensibility, seven hypoesthesias and one hyperesthesia. The localisations of the hypoesthesia involved in all cases the ventral thigh, and in one case the scrotum and pubic region (pat. 8). The hyperesthesia involved the proximal thigh (pat. 3). Some patients described a decreasing tendency of sensory symptoms over time. One patient of the LTRN- group was disabled due to the chronic pain (pat. 5).Two Patients had over 18 points suggesting neuropathic pain, two patients had less than 13 points, and the rest was in the undifferentiated zone. All patients of the control group had less than 13 points with the vast majority of them being at 0 Table .Table 4Pp = 0.031). The next factor influencing the development of chronic pain was the young age without reaching a significant level (p = 0.07).LTRN-patients had still significantly lower quality of life after the neurectomy compared with the control group in all 8 scales of the SF-36, except the emotional role function Table . The co-In this study we performed a retrospective analysis of patients treated with a transabdominal laparoscopic neurectomy for chronic pain after operations of the groin or right lower abdomen. Several therapeutic approaches have been recommended in order to treat chronic postoperative groin pain. To the best of our knowledge, none of the existing studies has evaluated the quality of life of those patients.Giger used an endoscopic retroperitoneal approach in 39 patients with chronic groin pain, describing complete pain relief in 80% of the cases, a transient relief in 16% . The genVuilleumier used an open approach to perform a radical IIN and IHN neurectomy after mesh removal without routinely dissecting the GFN, having 95% pain relief in 49 patients . Kline pIn our study 7 of our patients described a clear improvement of their pain, whereas 2 did not report any change. Furthermore, we saw that the quality of life of these patients despite the mildness of the pain is significantly reduced in all aspects compared with the control group except the emotional role function. The SF-36 values of the control group were similar to reference values on normal population according to other published studies .Chronic postoperative pain after surgery of the right lower abdomen and inguinal region is an underestimated problem . VariousSurgical treatment clearly plays an important role in the treatment of chronic debilitating neuropathic pain. The surgical approach and the way the neurectomy should be performed, is so far not exactly defined. The standard anterior two-stage approach offers the advantage of recognizing direct damage of the situs, involving nerve entrapment, hematoma or adhesions which could explain chronic pain and simultaneously intervene.The main disadvantage is that the situs is difficult to explore because of severe adhesions and scars, often resulting in additional damage, wound healing disorders, and longer hospitalisation, without resolving the symptoms.Furthermore, in the case of neuropathic pain, the nerve may not be resectable proximally to the damage which may lead to persistent pain due to remaining parts of the unresected, damaged nerve or secondary neuroma formation. In our series, all resected nerves were histologically examined. In 4 cases the pathological report revealed nerve fibrosis, although the nerve was resected proximally enough to the suspected area of damage. In one case a traumatic damage with axonal degeneration was discovered. In the other 4 cases the histological report did not reveal any relevant pathological changes of the nerves.Minimal invasive non-anterior approaches to neurectomy offer the advantage of resecting the nerve proximally enough, in order to achieve pain relief. Further manipulation of the operated and therefore surgically inhostile area is avoided. Laparoscopy offers, according to various publications, similar - if not better results than the anterior approach , 15, 26.The advantage of the transabdominal laparoscopic surgical approach in comparison to the laparoscopic retroperitoneal approach lies on the preservation of the anatomical structures in a way, which is familiar to the surgeon. In addition, it offers the ability of using the already existing scars from old operations, as many of these patients have already undergone a laparoscopy. Through the laparoscopic transabdominal approach, the surgeon gains access to both sides, in case the patient has developed chronic neuropathic pain after a bilateral procedure. Other causes of abdominal pain, such as adhesions, can also be excluded during the laparoscopy.A possible disadvantage of the method is that local causes of chronic pain, such as meshoma or other inflammatory processes, cannot be ruled out or treated. A staged and careful selection of the patients could avoid such confounding factors. A recent study  postulatThe limitations of our study include the small number of the patients in the LTRN-group and the matching group. The optimal matching group would consist of patients previously treated with medication or intervention. We had initially planned a 1:3 matching, which could not be achieved for all patients, due to the long time interval from the primary operation to the neurectomy . Further limitations are the subjectivity of the way in which every patient or matching candidate understood the questions and the bias in the chronological way in which the questions were set, despite the fact that all patients were asked to fill out the questionnaires concerning the pain status at the time of the follow-up. The decision to perform the neurectomy was based on the clinical examination and the experience of the surgeon. Quantifiable techniques such as quantitative sensory testing were not implemented since the experience with this method was not enough at the time we performed the trial.Laparoscopic transabdominal neurectomy represents an optimal surgical approach in patients with chronic disabling postoperative groin pain requiring surgical treatment. This technique was feasible, safe and effective in our series to relieve chronic debilitating pain in the majority of our patients with comparable results to other published approaches.


The present study tested the clinical efficiency  of a widely used pain assessment system, the Mandarin version of the American Pain Society Patient Outcome Questionnaire (APS-POQ-R-C), in Chinese patients. We also attempted to investigate the current quality of pain management provided in orthopedic inpatient units in China and provide baseline data. First, we investigated the test–retest reliability of APS-POQ-R-C. In total, 236 orthopedic patients were evaluated. Our results showed that APS-POQ-R-C has satisfactory internal consistency and construct validity, although some items are not appropriate for orthopedic patients. Test–retest reliability outcomes indicated that APS-POQ-R-C is a satisfactory battery with acceptable validity and reliability, and is therefore recommended for pain management in future studies. Pain is one of the most common symptoms associated with many disorders, is more frequent in surgical and cancer patients –5. UnrelPain is a subjective experience encompassing multiple dimensions , 15. In The aim of the present study is to test the item grouping, internal consistency of the instrument subscales, construct validity, and clinical feasibility of the Mandarin version of APS-POQ-R (APS-POQ-R-C) in Chinese orthopedic patients. We also investigated the relationships among items, subscales, and variables, which may potentially play a role in the prediction of outcomes affected by regional environments, cultural traditions, and native background behind the reported methods. We attempt to investigate the current quality of pain management provided in orthopedic inpatient units of China and provide baseline data. Moreover, we investigated the test–retest reliability of APS-POQ-R-C in the present study.The Mandarin version of APS-POQ-R was obtained directly from the American Pain Society website, which can be freely used without further permission. The questionnaire consists of 22 items, including pain severity (P1–P3), pain interference , adverse drug effects (P6), pain relief, participation in decision-making, satisfaction, and received pain treatment information. (P7–P10), nonpharmacological methods for treating pain , and whether patients received the help from investigators when completing the questionnaire (P13). Patients should read and sign informed consent at the beginning of the questionnaire.During the preliminary investigation, we found it was difficult for the patients undergoing spine or hip joint surgery to complete the item of activities out of bed (P4b) because of the requirement of local or systemic immobilization in the first 24 h after surgery. Patients were usually confused by the major reason of disability, namely, by pain or by immobilization requirements. However, in order to retain the integrity of the scale, the item was not removed in subsequent tests. In this case, many subsequent attempts were made to make the patient understand the context of the question. Only 2 patients were usually confused and we excluded their responses and included them into blank forms.A number of patients could not clearly distinguish the pain level (maximum or minimum), and may possibly have reported the same pain level. In this regard, two items  were somewhat difficult for patients to report. We therefore supplemented the definition of “severe pain,” namely, a pain experience causing bad effect, according to a previous study .All patients were recruited into the cohort from the 50-bed ward of an orthopedics department of a 1216-bed comprehensive university hospital (February 2016 to June 2016). Patients of this department include fractures and acute musculoskeletal injury, spinal injury, wrist arthroscopy, hand and wrist fusions, shoulder and elbow replacements, hip disorders, and knee ligament reconstruction. The present study complied with the Declaration of Helsinki of the World Medical Association (2000), and was approved and supervised by the Ethics Committee of Huashan Hospital of Fudan University . Informed consent was obtained from each patient or their relatives after all procedures were fully explained. The patients were recruited using the same methods as a previous study [We used the same statistical analyzing methods as in a previous study . BrieflyA total of 249 questionnaires were returned from 269 eligible participants (20 cases declined); of these, 236 were analyzed , for a response rate of 92.6%. The average completion time of the questionnaire was approximately 10 min . The final participation rate was 87.7%.2 = 1229.8; p < 0.001); therefore, the indicated factor analysis was applicable. Six factors with Eigenvalues over 1 were identified, while the 67.57% total variance was explained.Regarding the initial component loading matrix of APS-POQ-R, the KMO was 0.80 while the probability value of Bartlett sphericity test was low , which was isolated as a single factor, the initial results were similar to the subscales classified in original version, which were labeled with affective subscale (4 variables: P5a–P5d), pain severity and sleep interference subscale , perceptions of care subscale (3 variables: P7–P9), activity interference subscale , and adverse drug reaction (ADR) subscale .We also investigated the Cronbach’s α and the corrected item-total correlation of total scale and subscales. The Cronbach’s α of initial total APS-POQ-R-C was 0.798, whereas the value based on standardized items was 0.820. The items were adjusted according to the results of accompanying changes of α value of total scale and subscales supervening after item deletion. Four items, namely, “activity interference out of bed” , “severity of nausea” , “severity of drowsiness” , and “participation of pain treatment decision” , may increase the total α if deleted. After rounding, only deletion of P4b could enhance the α value. Spinal and hip joint surgery required immobilization after operation; thus, these patients could not get out of the bed, which was why some patients did not complete the interference section, in contrast to patients undergoing surgery on other parts of the body. In this regard, this item may not be appropriate for the patients strictly confined to bed.Moreover, the loading coefficient of the itching item on the component of other 3 ADR items was 0.057, distinct from others 3, ; we attempted to retained the itching item in ADR subscales but it lowered α of ADR subscale to <0.6. The items of “activity interference out of bed” and “severity of itching” were therefore removed and the validity and reliability of the adjusted APS-POQ-R-C were recalculated.As to the test–retest reliability of the final APS-POQ-R-C (obtained from 26 patients). The correlation coefficient of the subscales and total scales between two tests of final APS-POQ-R-C were extremely high (0.714–0.914). As for the independent sample test, no significant difference was found among the 4 subscales and total scales between two tests. The intraclass correlation coefficient (ICC) were >0.80 for total scale, and >0.75 for all subscales, except that the perception of care subscale was 0.654. According to these results, the test–retest reliability of the final APS-POO-R-C was verified.Tests of independent samples were employed to assess the differences of APS-POQ-R-C survey results between patients undergoing nonpharmacological therapy and those without nonpharmacological therapy. Of the 16 items in the scale, only “the level of percentage of time spent in severe pain” and “pain interference with falling asleep”  were significantly higher in patients undergoing nonpharmacological therapy. No difference was found in the “patient satisfaction,” “participation in decision-making” and other items .2 = 0.29, F = 20.36, p < 0.001). Our data indicated that these five items may be important components that influence pain satisfaction in patients  and APS-POQ-R 2010) is well documented  is well , 17, 27,Moreover, several differences were found in comparison with the previously investigated American original ASP-POQ-R  and the We also found that the Cronbach’s α of the ADR subscale in the present study (0.609) was slight lower than that in the American study (0.609 vs. 0.63) and the Icelandic study (0.609 vs. 0.75 respectively) , 16. OneWith regard to the results comparing the difference between patients undergoing nonpharmacological therapy and those without nonpharmacological therapy, only the scores of 2 items, namely “percentage of time spent in severe pain” along with “pain interference with falling asleep” were significantly higher in the nonpharmacological group. There was no difference for the “degree of the satisfaction and participation” between the two groups. Different from the American version, patients in the nonpharmacological methods group had significantly lower satisfaction scores and significantly higher “worst pain” scores.Along with the items of “pain relief” (P7) and “level of participation” (P8) in the American version, other predictors, namely “least pain” (P1), “depression” (P5b), and “activity interference in bed” (P4a) were also included in the APS-POQ-R-C; however, “the time in severe pain” (P3) and “information received” (P10) in the American version were not included. When the subscales scores were selected as the independent items, only the items of “pain severity and interference” subscale and “affective subscale” demonstrated a significant contribution to the changes of “satisfaction” or “perception of care” subscale, while the ADR subscales did not influence the result.The test–retest reliability of the APS-POQ was first verified in the present study. Spearman correlation and ICC are usually employed as indicators of reliability coefficient, while the ICC is more rigorous. Both indexes were adopted in this study to test the test–retest reliability. Test–retest reliabilities for each of the 4 subscales along with the total scale were statistically significant (p < 0.001). Except for the ICC of “perception of care” subscale of 0.654, which was acceptable and might be caused by some patients confusing the items of “satisfaction and participation concerning pain care” with the “investigation of medical or nursing quality,” other subscales showed very satisfactory retest reliability coefficients (0.769–0.920). Good test–retest reliability of the first three factors  indicated a minimal measurement error related to random variance . Our tesTaken together, the present study first investigated APS-POQ-R-C among Chinese orthopedic patients. However, we selected different patients from the previous studies in different languages, and it is difficult to draw a conclusion by simply comparing the present study with the previous ones. Our data indicate that APS-POQ-R-C has satisfactory internal consistency and construct validity in general. Moreover, the results of the test–retest further indicated that APS-POQ-R-C is valid and reliable, and is therefore recommended for pain management in Chinese orthopedic patients.