Cannabis sativa L.—based medicinal cannabis products for treatment of cancer associated chronic pains has gained increased interest in recent years. To ensure a controlled distribution of these products and investigate their therapeutic potential, several countries have established so-called pilot trials. Many doctors, however, are hesitant to prescribe medicinal cannabis primarily due to lack of research evidence regarding the products’ efficacy, safety and thus questionable dosing guidelines. This review aims to elucidate clinical research supporting administration of medicinal cannabis in cancer patients for analgesic purposes. The cannabinoids’ effects on the endocannabinoid system (ECS) and its implication in pain regulation is included to illustrate the complexity related to this research field. Published clinical studies on medicinal cannabis primarily consist of observational studies and only one pilot randomized controlled trial (RCT), where more RCTs exist on the cannabis-based product, Sativex® . The studies indicate analgesic potential, however non-significantly, for most patients and with acceptable safety profile. Summarizing, high-quality RCTs are scarce in this research field, and the limitations of the observational studies complicates interpretation of clinical outcomes. Despite discrepancy among the studies, they do show indications for administration and dosing regimens providing analgesic effects for some cancer patients.The analgesic potential of  Cannabis sativa L.) as an alternative to conventional medicines in the management of various diseases and disease-related symptoms, including cancer-associated pain, has increased massively during the last decades ® in advanced cancer patients (N = 177) being treatment-resistant to opioids was conducted in 2010 [® provided significant (p = 0.014) pain relief, with 43% reporting more than 30% reduction in numerical rating scale (NRS) pain score, compared to 21% in the placebo group (p = 0.006). The THC extract provided non-significant (p = 0.245) pain relief. An extension trial [® to be well-tolerated for at least 5 weeks treatment duration. Another RCT conducted by Portenoy et al. [® dose escalations in cancer patients refractory to opioids. Sativex® was administered at different dosage levels, i.e., low (1–4 sprays/day), medium (6–10 sprays/day) or high (11–16 sprays/day) during a 5-week treatment-period. The study found that low to medium dosing of Sativex® exerted improved pain relief compared to placebo. Adverse effects were dose-related, with the Sativex® high dosage group experiencing unfavorable adverse effects, with dizziness and vomiting being prevalent, compared to placebo and low-medium dosage groups. In addition, two RCTs were conducted by Fallon et al. in 2017 [® treatment in opioid refractory cancer patients in the U.S. Endpoint percentage improvement in pain score (>30%) was not met but patients did however show improvement in quality of life based on questionnaires. At the baseline of the first trial, subgroup analyses revealed that patients below 65 years of age reported lower opioid consumption and higher pain scores. Sativex® exerted significant (p = 0.04) pain relief in this subgroup population. This tendency was hypothesized by the researchers to be caused by the lower background opioid consumption resulting in a lack of opioid receptor downregulation thus allowing a higher synergistic effect among the opioid and cannabinoid receptors to occur, potentially leading to an increased pain relief from Sativex® consumption, which was outlined within the 1st RCT by Fallon et al. [p = 0.09) pain reduction from adjunctive Sativex® consumption compared to placebo in cancer patients refractory to co-consumed optimized opioid treatment. However, it was stated by the researchers that Sativex® might be a beneficial analgesic in cancer patients consuming low doses of opioids. Again, a tendency for significant beneficial effects of Sativex® within a subgroup of U.S. patients was observed upon secondary endpoints, such as average and worst pain, sleep, and background opioid consumption patterns. It was additionally observed that U.S. patients at baseline consumed lower doses of opioids.The first randomized controlled trial (RCT) investigating the analgesic effect of Sativex in 2010 . The clion trial  found coy et al.  evaluate in 2017 , which an et al. . Another® on chemotherapy-induced neuropathic pain was reported by Lynch et al. [® induced a clinical non-significant relief in pain intensity (stated as a two-point or greater pain reduction on NRS-PI). However, a responder analysis revealed a tendency in favor of Sativex® compared to placebo. It was concluded that Sativex® is worth investigating further in big RCTs in relation to specifically chemotherapy-induced neuropathic pain.A pilot RCT (N = 16) investigating exclusively the analgesic effects of Sativexh et al.  The stud® on cancer pain. The meta-analysis only included phase II and III trials thereby excluding the study by Lynch et al. [® on pain reduction, with only the phase II study by Johnson et al. [® consumption. Adverse effects with following dropouts were commonly observed across the studies, mainly dizziness, nausea, vomiting and somnolence. The risk of bias within the included studies of the meta-analysis were assessed by Boland et al. to be low in all domains, based on the Cochrane Collaboration risk of bias tool for RCTs [® as analgesic to cancer patients. However, the meta-analysis’ forest plots assessing the change in pain intensity do show a tendency in favor of Sativex® over placebo, which is supported by the outcomes of the individual RCTs as outlined in Recently, a systemic review and meta-analysis was conducted , coverinh et al.  due to ih et al. ,63,64,65n et al.  showing for RCTs . It was ® in cancer pain [Several study limitations were found associated with the included RCTs, such as self-reported pain through VAS, NPS, NRS and NRS-PI scores (which does not detect the complexity related to cancer pain), inaccurate usage of the oromucosal spray , high patient withdrawal and mortality rates , potential underdosing of cannabis-containing products to avoid potential adverse effects  and maintenance of background opioid consumption in several studies (increasing risk of adverse effects) ,67. It wcer pain .Clinical studies have yet to address specific pharmacological factors associated with the administration and dosing of medicinal cannabis. The clinical studies covered by this review do, however, contain data on route of administration, dose, and dosing frequency, as summarized in Only general observations regarding administration and dosing parameters were outlined in the clinical studies focusing on medicinal cannabis , see ®’ analgesic effects on cancer pain. The oromucosal spray Sativex® contains, as previously mentioned; 2.7 mg THC and 2.5 mg CBD per 100 μL, which is equivalent to one actuation of the spray pump [® at low  and medium  doses are well tolerated with sustained efficacy over a 5-week period [A systematic review was conducted with the aim to elucidate specifically the existing pharmacological evidence of medicinal cannabis administered to cancer patients . Four clray pump . Data frk period . Howeverk period ,71. In rk period .A recently published article  outlinedCannabis in general possess a superior safety profile compared to, e.g., opioids, with no reported death due to overdosing of cannabis, expected to be due to sparse CB1R localization within the brainstem region containing the respiratory centers ,75. Side® RCTs addressed in this review  affect opioid background dose co-consumption when study data were pooled in the meta-analysis. These findings were supported by another systemic review and meta-analysis performed by Noori et al. [The Sativexs review  have all opioids . This wa opioids , where ln et al.  Based upn et al. ,64,65 . In summary, these studies suggest potential beneficial effects of co-administering cannabinoids as adjunctive analgesic in cancer patients not satisfactorily pain relieved from their opioid therapy.These potentially synergistic effects of opioid-cannabinoid co-consumption are supported by pre-clinical studies and knowledge of similarities among cannabinoid and opioid receptors, their localizations within the body and the intracellular mechanisms they induce  and drug product  within and across batches [This review has focused solely on medicinal cannabis  and the natural cannabis extract product Sativex batches . Medicin®. The RCTs—as stand-alone studies—confirm some analgesic effect with a good safety profile. However, a recent systematic review and meta-analysis based upon these RCTs failed to demonstrate a significant analgesic effect of Sativex® in cancer patients.Based on published research literature included in this selective review, it is evident that there is a clear lack of high-quality interventional studies of gold-standard RCT design investigating the usage of medicinal cannabis  as analgesic in cancer patients. However, some observation-based studies have been performed, which in general indicate analgesic potentials for most cancer patients. Higher quality clinical research, i.e., RCTs have been performed regarding the cannabis-based medicinal product SativexAdministration and dosing guidance of this review).Clinical studies performed by gold standard methods are in general scarce and needed, as these—depending on clinical outcome—will allow for the conduction of solid evidence-based dosing and administration guidelines of medicinal cannabis products associated with the optimal efficacy and safety profiles for chronic pain cancer patients . Howeverdirections for use of medicinal cannabis products and ultimately provide the best possible treatment plan for the highly heterogenous cancer patient population, in line with a personalized treatment approach.Clinical evidence is currently not strong enough to determine if medicinal cannabis, or cannabinoid-based products, provide adequate, equal, or increased analgesic effects compared to available conventional treatments such as opioids across the population of cancer patients. The opioid-sparing effects that these products have been observed and proposed to exert in some patients could offer a potential advantage to many patients experiencing opioid treatment resistance and adverse effects . Howevertreasure trove, as it contains multiple bioactive compounds possessing therapeutic potentials [The cannabis plant has been referred to as a tentials . This hotentials , pp. 143tentials . Indepententials .


The role of emergency shockwave lithotripsy (SWL) in persistent pain control in patients with ureteral stones is not well established. The aim of this study is to evaluate efficacy as well as the predicting variables for successful early SWL patients with symptomatic ureteral stones. Eighty-six patients with a persistent renal colic secondary to single ureteral stone (6–12 mm) were prospectively enrolled in this study. SWL was performed within 24 h of the onset of flank pain. Pain control and stone-free rate after emergency SWL session were 58.1% and 44.2%, respectively. Seven patients required post-SWL ureteroscopy and ureteral stent placement for uncontrolled pain. The overall 3-month stone-free rate after SWL monotherapy was 83.7%. On multivariate analysis, predictors for pain relief after emergency SWL were lower Hounsfield (HU) stone density, mild hydronephrosis (HN) at presentation and presentation during the first colic episode. Lower HU stone density was the single predictor of successful stone clearance after single emergency SWL session on multivariate analysis. In conclusion, early SWL is feasible and effective in management of ureteral stones presented by renal colic with low HU. The prevalence of nephrolithiasis is reported to be 13% . AlthougTraditionally, after control of pain, the definitive treatment of stones was delayed with options including medical expulsive therapy (MET), SWL, and ureteroscopy . RecentlIn this study, we evaluate the efficacy as well as the predicting factors for successful emergency SWL in patients with persistent flank pain despite of receiving medical treatment.After the approval of our institutional ethical review board, we conducted a prospective study including adults presented to emergency department of our hospital between July 2008 and June 2011 for acute renal colic. Persistent flank pain was defined as uncontrolled pain after receiving 2 doses of 30 mg of intravenous Ketorolac within 6 h. Inclusion criteria were patients who are 18 year old or older with persistent flank pain secondary to medium sized single ureteral stone (6–12 mm).We excluded from this study patients with history of surgical intervention, patients with evidence of urinary tract infection and or renal failure, patients with stone size > 12 mm or less than 6 mm, marked hydronephrosis or peri-renal urinoma, patients with ureteral stricture and patients with solitary kidney or bilateral hydronephrosis.p value < 0.05 and 95% power.Sample size calculation was carried out using Epi-info™, version 3.3 . A calculated sample of 73 or more was needed, with a A total of 163 patients were assessed for eligibility. Monitoring of vital signs, plain X-ray of the urinary tract (KUB), abdominal ultrasound, non-contrast computed tomography (NCCT) of the abdomen and pelvis, urinalysis, complete blood count, and coagulation profile were done for all patients.Characterization of the stone was based on the KUB and NCCT imaging and included stone size , stone location , stone outline (smooth or irregular), and stone density measured by Hounsfield units (HU). Radiography with KUB was performed in all patients to assess whether the stone was radio-opaque or not. The presence of hydronephrosis was defined by ultrasound and patients were divided into 3 groups according to the degree of HN. Mild HN if the renal pelvis only was dilated, moderate HN if the renal pelvis and some calices were dilated, and severe HN if had severe uniform dilatation of the renal pelvis and calices with cortical thinning.Based on our inclusion and exclusion criteria, 86 patients  were included in the study and a written consent was signed. They underwent emergency extracorporeal shock wave lithotripsy (SWL) as soon as possible (within 24 h of the onset of colicky pain) using a Dornier Lithotripter S with dual ultrasound/fluoroscopic monitoring. All patients received intravenous perfusion of 500 ml saline, 1 gm of IV first-generation cephalosporin and 30 mg ketorolac IV 20 min before the session. No anesthesia was used, but 0.1 mg/kg diluted IV morphine was given during the session.Lumbar ureteral stones were fragmented with the patient in the supine position, iliac and pelvic stones in prone position. SWL protocol with a total count of 4000 SW/session at power of 16–20 kV and frequency of 60–70/min was utilized.The primary end point after the emergency SWL was pain relief (VPAS ≤ 3) after the SWL session and the secondary end point was stone clearance which was checked with ultrasound and KUB at the end of session or CT KUB if needed, as well as 3 weeks later.U test compare the non-categorical data. A multiple regression model was used for factors maintaining a statistically significant impact on the time to stone clearance, indicating that they act independently.Statistical analysis was performed using inter-cooled STATA®, (version 9.2). A univariate analysis was done to compare the two treatment groups. Analysis included the Chi-square test or Fisher’s exact test for comparison of the categorical data, and the Mann–Whitney Eighty-six patients were enrolled; the basic characteristics of patients at presentation are summarized in Table Pain relief (VPAS ≤ 3) and stone-free rate after emergency SWL session were 58.1% and 44.2%, respectively. Refractory pain (VPAS ≥ 7) occurred in 11 patients (12.7%); of them 7 required urgent ureteroscopy. The remaining 25 patients (29%) reported a controlled (tolerable) pain with VPAS (4–6) and of them 24 required a second SWL session  was 83.7%. Ureteroscopy was used in  patients after first, second and third SWL sessions, respectively, i.e., a total of 14 patients (16.2%).p = 0.016), mild HN at presentation  and presentation during the first colic episode .On multivariate analysis, predictors for pain relief after emergency SWL were lower HU stone density  (Table p = 0.004)  Table . Lower H4) Table .Table 2PDespite of the well-established role of SWL as a minimally invasive tool for the management of ureteral stones, there has been no consensus about its role in the emergency setting especially in those with refractory renal colic. Nowadays with the revolutionary improvements of SWL machines and their readily availability such a role has to be legitimately established .Many factors affect the choice of the modality of ureteral stone treatment. For ureteral stones > 6 mm, both URS and SWL have higher stone-free rate compared to medical expulsive therapy. Both modalities will render the patient more rapidly stone free without the prolonged use of multiple medications and minimize trips to the emergency department for pain control .The balance between SWL and URS is not that simple. With an overall stone-free rate of 90%, URS may exemplify an over treatment considering that the patient will undergo a surgical procedure under anesthesia with the possible complications of both . Since iIn this study, emergency SWL was effective in pain control in 58.1% of patients. The predictor for success pain control was low HU stone density. In addition, 44.2% of patients were stone free after emergency SWL session. Predictors for stone clearance were lower HU stone density, mild HN at presentation and presentation during the first colic episode.Panah A et al., found that stone size and Hounsfield units are important factors that affect the success of the emergency SWL, this was in agreement with our study which found that Lower HU stone density was also the single predictor of successful stone clearance after single emergency SWL session on multivariate analysis .Cornelius et al. showed different results when they compared success rate of early SWL versus delayed SWL and found that BMI > 30 is the predictor of stone-free rate on multivariate analysis . While GTo the best of our knowledge, this study is the first one to investigate the predictors of successful SWL and pain relief during the acute attack of renal colic. We found that lower HU stone density, mild HN at presentation and presentation during the first colic episode are predictors for pain relief.Emergency SWL is an effective modality combining both pain relief and the definitive treatment of ureteral stones. Our analysis indicate that patients who present during the first colic episode with mild backpressure changes and have low HU stone density are the most likely to benefit from this approach.


Musculoskeletal (MSK) pain disproportionately affects people from different ethnic backgrounds through higher burden and less access to care. Digital care programs (DCPs) can improve access and help reduce inequities. However, the outcomes of such programs based on race and ethnicity have yet to be studied.We aimed to assess the impact of race and ethnicity on engagement and outcomes in a multimodal DCP for MSK pain.This was an ad hoc analysis of an ongoing decentralized single-arm investigation into engagement and clinical-related outcomes after a multimodal DCP in patients with MSK conditions. Patients were stratified by self-reported racial and ethnic group, and their engagement and outcome changes between baseline and 12 weeks were compared using latent growth curve analysis. Outcomes included program engagement (number of sessions), self-reported pain scores, likelihood of surgery, Generalized Anxiety Disorder 7-item scale, Patient Health Questionnaire 9-item, and Work Productivity and Activity Impairment. A minimum clinically important difference (MCID) of 30% was calculated for pain, and multivariable logistic regression was performed to evaluate race as an independent predictor of meeting the MCID.P=.04) than non-Hispanic White patients. Hispanic and Black patients reported the highest level of pain, surgical intent, work productivity, and impairment in activities of daily living at baseline. All race groups showed a significant improvement in all outcomes, with Black and Hispanic patients reporting the greatest improvements in clinical outcomes. Hispanic patients also had the highest response rate for pain (75.8%) and a higher OR of meeting the pain MCID , when compared with non-Hispanic White patients, independent of age, BMI, sex, therapy type, education level, and employment status. No differences in mental health outcomes were found between race and ethnic groups.A total of 6949 patients completed the program: 65.5% (4554/6949) of them were non-Hispanic White, 10.8% (749/6949) were Black, 9.7% (673/6949) were Asian, 9.2% (636/6949) were Hispanic, and 4.8% (337/6949) were of other racial or ethnic backgrounds. The population studied was diverse and followed the proportions of the US population. All groups reported high engagement and satisfaction, with Hispanic and Black patients ranking first among satisfaction despite lower engagement. Black patients had a higher likelihood to drop out (odds ratio [OR] 1.19, 95% CI 1.01-1.40, This study advocates for the utility of a DCP in improving access to MSK care and promoting health equity. Engagement and satisfaction rates were high in all the groups. Black and Hispanic patients had higher MSK burden at baseline and lower engagement but also reported higher improvements, with Hispanic patients presenting a higher likelihood of pain improvement. Musculoskeletal (MSK) pain affects approximately 1.71 billion people worldwide . MSK paiA new era of telehealth, specifically digital physical therapy, has recently emerged and been brought to the forefront of the COVID-19 pandemic . These dDespite the many benefits of telehealth, inequities remain based on age, income, health education, digital literacy, and English proficiency -23. IndiWeber et al  reportedTo our knowledge, no study has been conducted on the impact of race and ethnicity on engagement and outcomes following telerehabilitation for MSK pain. Previously, we have reported clinical studies with a multimodal DCP that combined exercise-based physical therapy with psychoeducational components via a comprehensive approach to pain management -19,34,35This study was an ad hoc analysis of an ongoing decentralized single-arm clinical trial investigating engagement and clinical-related outcomes after multimodal DCP in patients with MSK conditions. The home-based DCP was delivered between June 29, 2020, and May 26, 2022.The trial was prospectively registered at ClinicalTrials.gov (NCT04092946) on September 17, 2019, and approved by the New England Institutional Review Board (number 120190313) on June 18, 2020.Adults (aged ≥18 years) from 50 states and the District of Columbia in the US beneficiaries of health plans covering the Sword Health program and reporting chronic MSK pain  were eligible to apply to Sword Health’s  DCP. Employees and their dependents were notified of their eligibility by their employer via email and on-site events and enrolled on the web for free through a dedicated website. During the enrollment phase, all participants were educated about the program and asked to provide informed consent to participate in the clinical trial. All participants completed a baseline form providing demographic data and details regarding their clinical condition, alongside specific questions to screen for potential clinical red flags, which were posteriorly assessed by an assigned physical therapist (PT) through an onboarding video call. The exclusion criteria were as follows: (1) a health condition  incompatible with at least 20 minutes of light-to-moderate exercise; (2) receiving treatment for active cancer; and (3) reporting any of the following signs and symptomatology, rapidly progressive loss of strength, numbness in either the arms or legs, unexplained changes in bowel or urinary function in the previous 2 weeks.DCP has been previously described elsewhere -19,34,35An onboarding call with an assigned PT is scheduled, which is then responsible for program tailoring (according to the specific condition) and monitoring. Personalized exercise sessions were performed independently at the patients’ convenience (at least three sessions per week were recommended). In case of a lack of internet access at home, a Wi-Fi hotspot was provided. Exercises were displayed on the tablet, with trackers allowing real-time video and audio biofeedback on performance. A cloud-based portal stored data related to exercise sessions , which enabled asynchronous and remote monitoring and adjustment by the assigned PT. The educational content provided was condition-specific, whereas CBT was general MSK pain-oriented. The educational component of the program was developed according to current clinical guidelines and research and included topics focused on anatomy, physiology, symptoms, evidence-based treatments, fear avoidance, and active coping skills . The CBT program was based on mindfulness, acceptance and commitment therapy, empathy-focused therapy, fear-avoidance behavior, and constructive coping. Education and CBT materials were delivered to the patients weekly through written articles, audio content, and interactive modules. Bidirectional communication with the assigned PT was ensured through a built-in secure chat within the smartphone app and video calls. Participants were considered dropouts if they did not engage in any exercise sessions for 28 consecutive days. Participants were included if they were compliant with the intervention but failed to complete a given reassessment survey.Demographic data collected included age, race, MSK condition, BMI, sex, educational level, and employment status. The race and ethnic groups included Asian, Black, Hispanic, other, and non-Hispanic White. The gender category included men, women, nonbinary, and “prefer not to specify.” A total of 8 educational levels were collected and then grouped as high school or less, some college including bachelor’s degree, and some graduate school including master’s and doctorate degrees. Furthermore, 8 employment status categories were collected and grouped as employed or not employed.Outcomes were collected at baseline and at 4, 8, and 12 weeks, and the mean changes were calculated between baseline and 12 weeks. These included the following:Patient engagement was measured as follows: (1) completion of the program (considered as the retention rate), (2) total number of completed exercise sessions over the 12 weeks, (3) total time spent performing exercise sessions, (4) mean number of sessions per week, (5) total articles read, (6) total interactions with the PT, and (7) overall satisfaction through the question: “On a scale from 0 to 10, how likely is it that you would recommend this intervention to a friend or neighbor?”Pain, using the Numerical Pain Rating Scale, through the question “Please rate your average pain over the last 7 days” from 0  to 10 (worst pain imaginable)”. A minimum clinically important difference (MCID) of 30% between the baseline and treatment end was calculated and analyzed ,38.Willingness to undergo surgery: “How likely are you to have surgery to address your condition in the next 12 months?” .Generalized Anxiety Disorder 7-item scale   was usedThe Work Productivity and Activity Impairment (WPAI) for general health questionnaire evaluated overall work impairment in employed participants , presenteeism (WPAI work), absenteeism (WPAI time), and activity impairment (WPAI activity) . Higher Patients were advised to report any adverse events to the dedicated PT through available communication channels for further assessment.t test, Mann-Whitney U test, 1-way ANOVA with Bonferroni post hoc, or chi-square test.A descriptive analysis of the study population demographics , clinical data, and engagement metrics was performed. Patients who completed the 12-week program were defined as “completers” and those that did not were defined as “noncompleters.” Statistical analysis between completers and noncompleters was performed using the 2-sample independent Latent growth curve analysis (LGCA) was used to estimate trajectories of outcome variables over time, as previously described . The anaA total of 9550 participants were enrolled, with 6949 (72.8%) patients having completed the program. The study flow diagram is presented in The patients’ baseline demographics for the entire cohort and for the different race and ethnic groups are presented in On average, participants had 49.4 (SD 12.9) years, a BMI of 29.2 (SD 6.7), and a pain score of 4.9 (SD 2.0). The cohort comprised 58.5% (5589/9550) women, 41.1% (3929/9550) men, 0.3% (24/9550) nonbinary patients, and 0.1% (8/9550) preferred not to answer. Therapy area distribution was similar to the prevalence reported for each MSK pain condition according to the United States Bone and Joint Initiative . The selP<.001; P<.001), a higher proportion of women (P<.001), and those with low back pain  and reported the lowest average BMI score .A larger proportion of full-time employed patients was observed within the Asian and Hispanic patient groups than in the other groups . Completers were older , with more patients reporting knee and shoulder pain and fewer patients reporting low back pain (P<.001). In addition, completers had a higher proportion of patients with a postgraduate education (P<.001). No differences were observed in employment status.Comparing completers (n=6949) with noncompleters (n=2601), no differences were observed between the proportions of the different race and ethnic groups . For example, pain levels were 5.0 (SD 2.0) in noncompleters and 4.9 (SD 2.0) in completers (P=.04).The overall completion rate was 72.8% (6949/9550). When stratifying dropouts by racial and ethnic groups, 20% (184/910) Asian, 23% (231/1025) Black, 25% (232/913) Hispanic, 20% (1224/6240) non-Hispanic White, and 20% (94/462) other racial and ethnic groups patients dropped out by the end of the program. The OR for being a dropout was estimated having non-Hispanic White patients as reference, Black patients: 1.14, 95% CI 0.97-1.34; Asian patients: 1.03, 95% CI 0.86-1.23; Hispanic patients: 1.19 95% CI 1.01-1.40; other patients: 0.95, 95% CI 0.74-1.21. Both Hispanic and Black patients seemed more likely to drop out than non-Hispanic White patients, although only Hispanic patients’ OR reached statistical significance (P=.006), younger patients (P<.001), patients with higher BMI scores (P<.001), less educated (P<.001), and those with spine conditions (P=.04) being more likely to drop out.The studied covariates influenced the obtained OR, with men (Completers performed an average of 30.1 (SD 20.0) sessions, comprising an average of 355.4 (SD 239.6) minutes of training time at an average of 2.8 (SD 1.1) sessions per week . The meaP<.001, P<.001, and P=.001, respectively), had less training time , and lower average number of sessions per week  when compared with non-Hispanic White patients. Black and non-Hispanic White patients read more articles (P<.001). Black and Hispanic patients were more satisfied with their treatment results .Across the different racial and ethnic groups, Black, Hispanic, and other patients participated in significantly fewer total sessions  and those in the other groups , with the exception of Asian patients When considering the recommended MCID for pain scores, 75.8% (157/207) Hispanic patients had a greater response rate at the 12-week assessment when compared with all other groups . The OR for the other race groups did not reach statistical significance. Both men (P=.007) and patients with upper limb pain (P<.001) were more likely to achieve MCID.To evaluate whether race and ethnicity was an independent factor for reaching MCID, logistic regression adjusted for BMI, age, sex, therapy area, education level, and employment status was performed with the non-Hispanic White race as the reference category. Hispanic patients  were more likely to achieve MCID than non-Hispanic White patients (P<.001) and within each racial and ethnic group at 12 weeks (P=.02) and non-Hispanic White patients .The mean surgical intent score was significantly reduced overall . Reductions were similar across all racial and ethnic groups in both anxiety and depression mean changes, with scores ranging between 3.19 and 4.91. Black patients exhibited the greatest reduction in GAD-7 , which was statistically different from non-Hispanic White patients , but not clinically relevant.A significant improvement in both mental health metrics was observed for the overall cohort compared with baseline when filtering for at least mild anxiety and depression at baseline (scores above 5)  and from other patients . Both Black  and Hispanic patients  recovered more from activities of daily living impairment than non-Hispanic White patients .For the overall cohort, there was a significant improvement in all WPAI domains compared with baseline: WPAI overall: 13.7, 95% CI 12.5-14.9,  P<.001; . Black pAmong the racial and ethnic groups studied, Black patients presented baseline demographic characteristics associated with poorer prognosis  than patients from other races and ethnicities.Regarding the clinical outcomes, significant pain reduction was observed in all racial and ethnic groups. Black and Hispanic patients reported the highest level of pain, surgical intent, work productivity, and impairment in activities of daily living at baseline. However, these same patients also reported the greatest reduction in surgery intention, work productivity, and activities of daily living impairment by program end, when compared with the other racial and ethnic groups. Black and Hispanic patients had a larger reduction in mean pain level scores than non-Hispanic White patients and those from the other groups; however, only Hispanic patients reported significantly greater response rates .To our knowledge, this is the first study to evaluate racial differences in engagement and outcomes for a completely remote, multimodal, digital care plan for MSK pain. Several reports have shown that people from racial and ethnic minority groups do not access telehealth as often as non-Hispanic White patients ,27,32,33Overall engagement in the program was high, with a high satisfaction rate. Black and Hispanic patients dropped out more frequently than the other groups and had lower metrics for engagement. However, these 2 groups also had the highest satisfaction scores. Different combinations of factors might explain the lower engagement of Black and Hispanic patients with DCP. Aggravated baseline outcomes may be associated with poorer adherence ,51. AmonSignificant improvements in pain were observed at the completion of the program across all different racial and ethnic groups. However, it is known that pain is not equally experienced among different races and ethnicities ,25,30,31In addition, people from racial and ethnic minority groups have been shown to have worse outcomes than non-Hispanic White patients ,28,33. HBlack and Hispanic patients also had significantly higher baseline surgical intentions, which was not surprising given their higher pain scores. To our knowledge, no study has investigated racial or ethnic differences in surgical intent in a physical rehabilitation setting, which makes comparisons difficult.It is well established that MSK pain is associated with comorbid psychiatric illnesses, specifically depression and anxiety . In thisThis study has several limitations, the most relevant being the lack of a control group, which means that we cannot establish the program’s causal effect on pain or other clinical outcome improvements. Nevertheless, the large sample size and applied statistical analysis allowed not only to compare clinical status in a before and after scenario but also to compare the trajectories of distinct groups of patients, which was the main intent of this study. In addition, the fact that all patients had chronic MSK conditions provides a more homogeneous sample, where the natural history of the condition tends not to be as favorable as in cohorts of patients, including acute MSK pain.Our study participants may not be representative of the general adult population, as the study only included beneficiaries of specific benefits provided by their employers or covered by health plans offering the service, and who opted into a digital MSK program, which limits their applicability to clinical settings with higher proportions of uninsured, elder adults, or patients who are work-disabled.This study also does not control for all domains known as social determinants of health , which can influence both program use and health outcomes, and are known to disproportionately affect different racial and ethnic groups -27. LongFurther prospective controlled studies are warranted to better characterize the effects of race and ethnicity on digital therapy outcomes, namely, controlling for social determinants of health.Despite these limitations, the results provide evidence of program applicability in a real-world setting with a large sample size from a wide geographic representation (50 states and the District of Columbia in the United States), with a wide diversity of job types . Therefore, this cohort allows for a diverse population study, with large subgroup sample sizes enabling comparisons, which to the best of our knowledge, have not been reported before. Another strength is the DCP itself, which is a multimodal approach that includes exercises using real-time biofeedback, regular communication with the same PT, and a digital format, all of which favor accessibility and maximize engagement. An additional strength of this study is the use of validated outcome metrics for both physical and psychological outcomes, thereby permitting translational application and generalizability to other populations.This study is the first to evaluate racial differences in a completely remote, multimodal, DCP for MSK pain. The study population followed the proportions in the US population. All racial and ethnic groups experienced significant improvements in pain as well as high satisfaction rates at program completion. Black and Hispanic patients had significantly higher baseline outcome scores, lower engagement metrics, and higher dropout rates, but they also had higher satisfaction rates and improvements in those outcomes. Hispanic patients reported the higher response rate to pain. This study supports the use of DCPs to improve accessibility, while reinforcing the need to improve engagement strategies for Black and Hispanic patients.


Postoperative pain is a major concern following scoliosis surgery. CEA  is established in postoperative pain therapy as well as intravenous patient-controlled analgesia (IV-PCA). The purpose of this study was to compare the clinical outcomes of both methods.n = 93 vs. n = 30) and those who were impaired . The outcome parameters were the demand for pain medication, parameters of mobilization, and the presence of adverse reactions.We retrospectively studied 175 children between 8 and 18 years who were subject to posterior scoliosis correction and fusion. Two main cohorts were formed: CEA with local anesthetic and opioids, and IV-PCA with opioids. Both groups further comprised two sub-cohorts: those who were mentally and/or physically healthy . First postsurgical defecation was seen earlier in all children who received CEA in both groups . Healthy children who received CEA were discharged from hospital 4 days earlier than their IV-PCA counterparts (p < 0.001). No statistically significant difference in postoperative nausea nor in vomiting was identified between groups. Transient neurological irritations were seen in 9.7% of the patients in the CEA group.Healthy children who received CEA started mobilization 1 day earlier than children with IV-PCA (CEA provides appropriate pain management after scoliosis surgery, regardless of the patient’s mental status. It allows earlier postoperative defecation for all patients , as well as shorter hospitalization and an earlier mobilization for healthy patients. Tridimensional deformity of the spine, also known as scoliosis, can have a huge impact on the patients quality of life. Surgical correction of idiopathic scoliosis is considered for curves above 45–50° . Due to Postsurgery pain can be a very distressing feature of scoliosis surgery, and it can increase postoperative morbidity, complication rates, and length of hospitalization (LOH) . TherefoEpidural application of pain medication, such as continuous epidural analgesia (CEA), emerges as an efficient postoperative pain management method. It has been shown that epidural catheters can be used safely and are an efficient means of pain management  in patieIn scoliosis surgery, placing an epidural catheter after posterior correction is straightforward: The surgical field is prepared already and the placement itself does not require the spinal surgeon to have completed additional training. Thus, epidural catheters were used across multiple centers.However, whether CEA is superior to intravenous opioid therapy via IV-PC remains a matter of debate as contradictory data can be found in the literature.Despite the proven advantages in other applications, some concerns remain: catheters might be an additional source of infection by channeling the way for bacteria during their application; and, since they can only be applied in an inpatient setting, they can further prolong the hospital stay. This trial aims to answer the question of whether CEA provides better outcomes than IV-PCA in healthy and impaired children after Posterior Spinal Instrumented Fusion (PSIF).This study is a retrospective cohort analysis between 2004 and 2016, and has been approved by the institutional review board (#EK111032017). For pain management, IV-PCA was used until 2008 and switched to CEA in 2009.The patients were selected according to the following protocol Fig. .Fig. 1SeAll patients were subject to PSIF using multilevel pedicle screw constructs by various suppliers. Patients older than 18 years or who had modified procedures  were excluded. All patients were operated by JS, FT, or PB. Children received either IV-PCA or CEA for postoperative pain management. Data were provided through the patient records .H) are depicted with the symbol of a walking person , whereas the mentally and/or physically impaired children (I) are depicted by a wheelchair . An arrangement into different groups was necessary, as impaired children mostly mobilize via wheelchair, whereas healthy children mobilize independently. In addition, impaired children are often not able to communicate pain adequately or administer pain medication independently, so these groups had to be analyzed separately.Patients were divided into two groups on the basis of their mental and/or physical status into healthy and impaired. In this article, healthy children , so that four groups were formed. Table Table ) and 93 to the impaired group . Exclusion criteria are listed in Table Thus, from 368 patients, a total of 216 were eligible for analysis, 123 belonging to the healthy  and gently pushed cranially to secure for 5–8 cm epidural location Fig. .Fig. 2EpTo compare the efficiency of the pain-medication regimes, the following parameters were studied: Table Table 4PaFirst defecation and discharge from ICU were calculated as postoperative days and the length of hospital stay was counted in full days. First mobilization was defined as “standing in front of the bed” for healthy children and “transfer into the wheelchair” for impaired children.Assessment of pain was expressed through the number of times the patients administered drugs via the catheter or IV-PCA or demanded additional pain medication (rescue medication), such as opioids and non-opioids. Some of the impaired children were not able to operate the pump or ask for additional pain medication themselves. In these cases, the nursing staff or parents administered the pain medication. Nausea and vomiting were counted when mentioned in the patient notes.If an adverse reaction resulted in any further operative intervention, intensive medical treatment, or prolonged hospital stay, it was defined as a complication.Postoperative pain therapy via CEA was delivered by a continuous and patient-triggered application of Ropivacaine 0.2% + 0.5 μg/ml Sufentanil through the epidural catheter, the volume being adjusted to patient body weight and level of pain. Patients using IV-PCA for postoperative pain management were able to self-administer weight-adjusted boluses of Piritramide when feeling pain (bolus volume 2–4 ml). In this system, no continuous application was established as the administration of Piritramide was only done through bolus application (volume being adjusted to patient’s body weight).Weaning off the epidural catheter was started 3–4 days postsurgery by reducing the continuous rate and followed by removal of the catheter on the fifth day. During CEA—and IV-PCA weaning, as well as rescue medication, various drugs were used .p < 0.05. A comparison was explicitly carried out between the application systems within the same mental/physical status groups. Therefore, impaired children were never compared to healthy children.Statistical analysis was conducted using SPSS-statistics software. For significance detection, Chi-squared test, as well as the Mann–Whitney U test, were performed. Differences in means were considered significant when There was no statistically significant difference in terms of age, weight, and height between the groups. Age, sex distribution, instrumentation lengths, and duration of surgery of the patient groups are shown in Table p = 0.002). However, the same effect could not be reproduced for wheelchair mobilization in impaired children, who remained bed-bound for about 5 days, regardless of postoperative pain therapy  and 2 days in impaired children (p = 0.044)  Fig. b.p < 0.001). This effect was not as pronounced in impaired children  nor in vomiting , 34%–42% in impaired, (p = 0.569)) or in postoperative hypotension.No differences between the cohorts have been detected in occurrence of postoperative nausea  and no irritations in group 4. Sensory disturbances (upper or lower extremities) were seen in 6 cases. In 3 cases, patients described a hypoesthesia , and in 1 case, a paresis was found (upper extremities). The irritations were either treated through a change of therapy  or it resolved independently, without any change in therapy. In one case, an MRI was performed without any further therapeutic implications. All neurological deficits resolved completely during the hospital stay. No epidural leakage was found postoperatively.There were 2 severe complications, where a causing by the catheter could not be ruled out completely. One was an early wound infection in the epidural catheter group, which required surgical intervention. The other complication was a vegetative decompensation, presenting as hypotension and respiratory arrest after first commissioning of the epidural catheter.Due to the large wound area and the spinal correction, patients suffer from intense pain which can be a distressing and disabling side effect of scoliosis surgery. Most scoliosis centers use IV-opioids for postoperative pain management; however, these drugs are associated with considerable side effects .In our center, we settled on using CEA for postoperative analgesia. Technically, the placement of an epidural catheter at the end of a posterior spinal procedure is a straightforward procedure and should ameliorate the postoperative outcome.In our study, we showed that significant milestones of postoperative recovery, such as early bowel movement and mobilization, can be accelerated. Compared to IV-PCA-treatment, healthy children receiving CEA could be ambulated one day earlier. Both groups, healthy and impaired children, were found to have earlier bowel movements than their IV-PCA counterparts.Shrader [Pain is not only a distressing sensation, and it increases the complication rate as well as the LOH . EpiduraShrader . He repoShrader ..For this reason, studies proving the superiority of any pain medication regime in this particular group gain special emphasisSaito's [Gauger [Meng [We could not demonstrate the superiority of CEA over IV-PCA in pain management in our study. Yet, it was shown in several other trials for AIS , 10, 11 Saito's  study coer [Meng , 11, 12 It is known that CEA has a positive impact on early bowel movement . Early mCassady [Van Boerum [p = 0.03) than patients in the IV-PCA group.We found the first postsurgical defecation earlier in all groups receiving CEA compared to those with opioid analgesics. Similarly, findings were published by Cassady  whose dan Boerum  showed tOur results clearly show that non-impaired patients who received CEA after posterior spinal fusion in adolescent scoliosis are able to ambulate earlier than patients receiving IV-PCA. These findings are contradictory to other publications , 9, thatIn a few cases, installation and use of CEA might be associated with complications, such as hypotension or bronchoconstriction . NeuroloGauger [We observed one case of vegetative decompensation, presenting as hypotension and respiratory arrest after the first injection via the epidural catheter and transferring the patient into the bed. A similar case is described by Gauger , who repCassady [The occurrence of wound infection caused by the catheter is a rarely described complication in literature. Cassady  also fouAlthough prone to dysfunction in some patients, epidural catheters are generally safe –5 and doMeasuring postoperative pain remains one of the most important tasks in the surgical field. Since it is still a challenge to measure pain in a prospective manner, it is even more difficult to assess it retrospectively or to assess and compare the total amount of pain medication the patients have received. For this reason, the limitations of our study are of a retrospective nature. We were not able to use generally accepted tools, as the NRS, for it was not used back in 2004. Also, there might be a bias in, for example the LOH or the first time until first mobilization as IV-PCA was used before 2009 and CEA was used afterwards. Before 2009 the awareness of early first mobilization was not as high as it is today and LOH became an economic factor with changes in the German health care system.Klatt [A small number of CEA patients needed additional IV-PCA-support to ease the pain. Yet, this transfer was already seen in other trials , 10. KlaKlatt  describeThe applicability of CEA is limited in operations where multiple unclosed osteotomies are applied, because the local anesthetics leave the epidural space through the osteotomies. In cases of limited invasive scoliosis surgery , the insertion of the epidural catheter is not favorable.This study shows that the epidural catheter can be used as an effective means of postoperative pain management for children with scoliosis, irrespective of mental and non-mental disability. Our results verify that it is more effective than IV-PCA in postoperative pain management after posterior spinal fusion, measured by bowel movement, independent ambulation, and duration of hospital stay in non-impaired children. Regarding impaired children, it is more effective in the normalization of bowel movement, and equally effective in first ambulation, hospitalization, and treatment of postoperative pain.For non-impaired children, epidural pain therapy clearly accelerates postoperative mobilization, allowing standing up only a few hours after surgery.Therefore, in our center, the application of CEA after posterior scoliosis correction has become standard treatment.


An estimated 54 million Americans currently suffer from debilitating arthritis. Patients who have exhausted conservative measures can be subject to chronic pain and resort to symptomatic management with anti-inflammatories, acetaminophen, and opioids. Cannabidiol (CBD) is a non-psychoactive cannabinoid that has shown promise in preclinical studies to reduce inflammation and pain associated with arthritis. The purpose of this study was to explore patient perceived effects of cannabidiol on symptoms of arthritis.N=428) was recruited through online methods including social media accounts and newsletters (The Arthritis Foundation and Savvy Cooperative) between May 5, 2020, and November 5, 2020. Statistical analysis was performed to determine differences between types of arthritis and improvements in quality-of-life symptoms. Furthermore, a regression analysis was performed to identify variables associated with decreasing or discontinuing other medications.A novel anonymous questionnaire was created to evaluate perceived efficacy of cannabidiol for the treatment of arthritis. A self-selected convenience sample (P=0.013), favoring the osteoarthritis group. The overall cohort reported a 44% reduction in pain after CBD use (P<0.001). The osteoarthritis group had a greater percentage reduction (P=0.020) and point reduction (P<0.001) in pain compared to rheumatoid arthritis and other autoimmune arthritis. The majority of respondents reported a reduction or cessation of other medications after CBD use : reductions in anti-inflammatories , acetaminophen , opioids  and discontinuation of anti-inflammatories , acetaminophen , and opioids .CBD use was associated with improvements in pain (83%), physical function (66%), and sleep quality (66%). Subgroup analysis by diagnosis type  found improvements among groups for physical function (Clinicians and patients should be aware of the various alternative therapeutic options available to treat their symptoms of arthritis, especially in light of the increased accessibility to cannabidiol products. The present study found associations between CBD use and improvements in patient’s arthritis symptoms and reductions in other medications. Future research should focus on exploring the benefits of CBD use in this patient population with clinical trials.The online version contains supplementary material available at 10.1186/s42238-022-00154-9. Cannabis sativa plant. THC has well-established effects on pain but is associated with psychoactive effects, which may hinder its application in the pain-reduction setting  and delta-9-tetrahydrocannabinol (THC) are the most prevalent, pharmacologically active phytocannabinoids found in the Arthritis | CDC, Arthritis | CDC, An estimated 23% of all adults, or 54 million Americans, are suffering from arthritis, with osteoarthritis and rheumatoid arthritis (RA) constituting the majority  Do patients with arthritis report improving or worsening symptoms with CBD use? (II) Was CBD use associated with decreases in other pharmacologic treatments for patients with arthritis? (III) Were there any differences in reported symptoms based on the type of arthritis? With this study, we aim to demystify preclinical data that suggest CBD may have a role in the treatment of arthritic conditions.A survey was created to evaluate participants' perceived efficacy of CBD for their arthritis symptoms. The study was granted Institutional Review Board approval at the Feinstein Institute for Medical Research, part of Northwell Health, and patient consent was not necessary because it was anonymous. The questionnaire was designed based on the outline of survey creation described by Passmore et al. . AdditioBackground questions included demographic information, characteristics of CBD use, and previous treatment modalities. Questions consisted of “yes/no” and “select one of the following.” Questions regarding previous treatment modalities, the anatomical joint involved, and medications were in “check all that apply” formatting. Efficacy of CBD use for their pain and arthritis symptoms was assessed by a number of different outcome variables. Improvements in pain intensity were evaluated using a 5-point Likert scoring system, adopted from the Patient Global Impression of Change (PGIC), ranging from “much worse” to “much better.” A“Much Better” response has previously been validated and utilized as an indicator of clinically important benefit  were excluded. Furthermore, surveys were deemed incomplete by the authors if they were missing responses regarding the patient’s diagnosis of arthritis and/or CBD use (N=30). Those who had not tried CBD for their arthritis pain (N=176) were not included in the formal analysis; however, we did compare the difference in demographics between those that used CBD and those that did not (N=604). Our final outcome measures were evaluated for participants who had tried CBD (N=428).Participants were a self-selected convenience sample who accessed the online survey between May 5, 2020, and November 5, 2020. The survey interface was facilitated through REDCap electronic data capture software , and pain reduction (NRS) associated with age, sex, arthritis subtype, dose, frequency, and length of CBD use. Multivariate logistic regression models incorporating age, sex, arthritis subtype, dose, frequency, and length of CBD use were used to analyze the effect on other medication reduction or cessation. A two-tailed p-value less than 0.05 was considered statistically significant. All statistical analyses were performed with SPSS Statistics V26 .Descriptive statistics were performed to evaluate the demographics of the study population and questions without mutually exclusive answers. Pearson’s chi-squared test was used in the analysis of categorical variables. Numerical Rating Pain Scale point reduction and percent pain reduction were evaluated among arthritis groups with nonparametric Kruskal–Wallis tests. Individual pairwise comparisons were evaluated with Mann–Whitney N=164, 30%), 49.6% needed more information or evidence, 24% were unsure of side effects, 15% had concerns over the legality and drug testing, and 6% stated it was too expensive. Patients that used CBD were younger than patients who had not used CBD, X2 (N=604), P<.001, and were more likely from a Western state  X2 (N=604), P=.01. The remaining socioeconomic demographics were not different between the two groups (Table Most participants who completed the survey had tried CBD for symptomatic relief of arthritis (70%). Of the participants who had not tried CBD N=64, 30%, P<0.001), with slightly higher proportions of older patients in the OA group compared to RA and other autoimmune arthritis groups. There were no significant differences between groups with regards to gender, ethnicity, location, highest education, or income , hand , hip , shoulder , wrist , ankle , and elbow . For this question, participants could “check all that apply.” On the basis of the distribution, many patients had pain in multiple joints. Participants reported prior treatment with anti-inflammatories , acetaminophen , physical therapy , intra-articular steroid injection , and opioids .We compared demographics by type of arthritis and found a significant difference in age . Differences between groups were seen for subjective improvements in physical function (p=0.013) but not for pain (p=0.072) or sleep quality (p=0.214). Pairwise comparisons between groups for physical function demonstrated that patients with osteoarthritis had more positive responses on the Likert scale than did patients with other autoimmune arthritis (p=0.014)  was performed. With the exception of age, demographics were not significantly different between groups. Participants with osteoarthritis were more likely to be in the 55–64 age group (on p=0.01 but not p<0.001). Comparisons between diagnostic groups can be seen in Table p<0.001) . The overall cohort reported significant reductions in pain after CBD use, with a 44% reduction in numerical pain score and 2.58-point reduction (p<0.001) and length (p<0.001) of CBD use among arthritis groups (Table p<0.001). Furthermore, this increasing frequency was also associated with greater pain reduction according to the NRS (p<0.001). Similarly, increasing length of CBD use was associated with improvements in pain intensity, physical function, sleep quality (p<0.001), and greater NRS pain reduction (p<0.001).In noting differences in frequency , including a reduction in anti-inflammatories , discontinuation of anti-inflammatories , reduction in acetaminophen , discontinuation of acetaminophen , reduction in opioids , and discontinuation of opioids   reduced or discontinued medications, as compared to other autoimmune  and RA  respondents (p=0.068). Furthermore, participants who reduced or stopped medications reported increasing frequency of CBD use (p<0.001) and overall length of time utilizing CBD (p=0.004).Most respondents using CBD for joint pain reported a reduction or cessation of other medications due to CBD use N=259, 0.5%, incp=0.679) to reduce or stop the use of other medications, and participants in the RA group were 37% less likely  to reduce or stop the use of other medications (Table p=0.006) and more than once a day  were more likely to reduce or stop other medications as compared to those taking CBD less than once a month (Table p=0.020) , drowsiness/somnolence , increased or decreased appetite , dry eyes , impaired concentration , dizziness , headache , and digestive complaints   reported a reduction or discontinuation of opioids, acetaminophen, and/or anti-inflammatories. In terms of the perceived effects of CBD on pain, physical function, and sleep quality, many patients using CBD reported symptomatic improvements. Furthermore, we sought to determine if participants with different types of arthritis had differences in perceived benefits of CBD. Subgroup analysis based on arthritis etiology failed to show differences between groups in terms of pain improvement and sleep quality. The osteoarthritis group had improved subjective physical function scores compared to the autoimmune arthritis group; however, it is unknown if this statistical finding is clinically meaningful. In terms of pain improvement, participants reported a 44% reduction in pain and a 2.58-point difference in the NRS after using CBD. The magnitude of pain alleviation in our study participants, as measured by percentage reduction in pain or point difference, both surpass the clinically important differences reported in literature   and acetaminophen. Boureau et al. compared ibuprofen and paracetamol in patients with arthritis of the knee or hip and found superior pain reduction with NSAID use. Treatment with NSAIDs resulted in a 2.3-point reduction whereas paracetamol resulted in a 1.5-point reduction . Medications frequently prescribed to manage the symptoms of arthritis can have unwanted side effects. The use of anti-inflammatories has been associated with numerous complications, including the risk of serious gastrointestinal bleeding, ulcerations, and cardiovascular events  and once a day  were more likely to reduce or stop other medications, when compared to those who took the medication less than once a month. Similarly, patients taking CBD for a period of more than three years were 3.6 times more likely to reduce or cease other medications, when compared to those taking CBD for less than 30 days. One important consideration is that patients who reduce or stop other medications may also be more likely to use CBD regularly and for longer durations as a replacement for the alternative medications.Between the different arthritis types, a larger percentage of patients with osteoarthritis (66.2%) reported reductions in other medications used compared to RA (56.3%) and autoimmune arthritis (53.7%). Additionally, we noted that increased dosing frequency and length of use of CBD led to higher rates of other medication reduction and cessation. When controlling for age, dose, gender, the type of arthritis was not found to be an independent predictor. Patients who used CBD more than once a day (OR: 16.9, Despite all of the study participants having a diagnosis that was made by a physician, only 45.6% had spoken to a health care professional about CBD use for their condition. This may be because CBD is readily accessible and does not require a prescription. Another possibility is that healthcare professionals may not be discussing CBD use with their patients. Although CBD is available for purchase without consultation with a doctor, the authors recommend that patients discuss this with their doctor before use. Cannabidiol could have unwanted side effects and/or interactions with other medications. Most of the literature regarding the adverse events of CBD use has come from clinical trials for the FDA-approved indication to treat seizure disorders (Corroon & Kight, The study has limitations that must be considered when interpreting these results. First, the survey used was created by the authors and was based on clinical expertise as well as other published studies (Corroon and Phillips, Clinicians and patients should be aware of the various alternative therapeutic options available to treat their symptoms of arthritis, especially in light of the increased accessibility to cannabidiol products. The present study, while exploratory in nature, suggests there may be therapeutic benefits to CBD use and highlights the need for research in a field where the science lags behind popular use. Future research should focus on exploring the benefits of CBD use in this patient population with well-controlled clinical trials.Additional file 1.Additional file 2.


Idiopathic pulmonary fibrosis (IPF) is a chronic, progressive, fibrotic, and fatal interstitial lung disease (ILD) of unknown etiology that primarily affects the elderly. Patients with IPF suffer from a heavy symptom burden and usually have a poor quality of life. Dyspnea and dry cough are predominant symptoms of IPF. Although pain is not considered one of the main symptoms of IPF, it can occur for a variety of reasons, such as hypoxia, coughing, muscle and nerve damage, deconditioning, and steroid use. The prevalence of pain in IPF patients varies greatly, ranging from around 30 to 80%, with the prevalence being estimated mostly among patients in the end-of-life period. It manifests itself in the form of muscle pain, joint discomfort, or back and chest pain. Approaches to the treatment of chronic musculoskeletal pain in patients with IPF include pharmacological and non-pharmacological measures that are also important to optimize the treatment of other symptoms (dyspnea and cough) and the optimal treatment of comorbidities. Given the scarcity of data on this symptom in the literature, this article summarizes what is currently known about the etiology and treatment of musculoskeletal pain in IPF. Idiopathic pulmonary fibrosis (IPF) is a chronic, progressive fibrosing interstitial pneumonia of unknown origin with a median survival of 3–5 years after diagnosis, which is similar or even worse than the time course of many malignancies . Lung fiAt rest, IPF patients usually demonstrate restrictive pulmonary physiology with decreased forced vital capacity and total lung capacity, accompanied by impaired gas exchange as measured by the diffusion capacity of the lung for carbon monoxide . As the The aim of IPF treatment is to slow disease progression, reduce the frequency of acute exacerbations, increase survival, reduce symptoms, and improve overall health-related quality of life (HR-QoL). Currently, two anti-fibrotic medications are approved for the treatment of IPF (pirfenidone and nintedanib) . They caBecause IPF is more common in older patients and smokers, these patients are more likely to have multiple comorbidities, such as chronic obstructive pulmonary disease (COPD), emphysema, bronchiectasis, sleep apnea, pulmonary hypertension, lung cancer, cardiovascular diseases, pulmonary embolism, gastro-esophageal reflux disease (GORD), depression, anxiety . These cThe management of IPF is multifaceted, requiring collaboration among members of the healthcare team, family members, and caregivers to provide patient education and support, as well as management of symptoms, comorbidities, and palliative care . MusculoUsing selected keywords , we searched bibliographic databases PubMed, Medline, and Google Scholar for available meta-analysis, literature, and systematic reviews, as well as clinical studies where the musculoskeletal pain in patients with IPF and ILDs, in general, was analyzed. The research included relevant literature sources, only in English, that had been published within a 12-year period (2000–2022) and that met the following inclusion criteria: number of citations, year of publication, and educational significance of available information in a particular manuscript. All identified studies are presented and discussed in a non-selective manner. A total of 91 bibliographic sources were used in writing this paper. To the best of our knowledge, this is the first literature review describing research into musculoskeletal pain in IPF.Patients report that dyspnea, coughing, and fatigue have the greatest impact on their daily lives . AlthougThe prevalence of pain in IPF patients has been investigated in a small number of studies, and the results vary, with estimates ranging from 30 to 80%. The variations in the results can be explained by the different methodological approaches used in the research, as well as the fact that the patients in the studies were at different stages of their disease. The majority of research on pain in IPF included patients in their end-of-live period. Thus, in a study conducted by Rajala et al.  and AhmaMany patients cannot understand how a lung disease, such as IPF, can manifest into pain . Some of the underlying causes of pain in patients with IPF are as follows:Lack of oxygen (hypoxia)Patients with advanced IPF develop hypoxia (reduction of oxygen levels in cells and tissues) due to multiple physiologic derangements, including diffusion limitation, ventilation-perfusion mismatching, and abnormalities of the pulmonary vasculature . HypoxiaCoughingCoughing is common in patients with IPF , 27–29. Muscle and nerve damageAnother and likely less common reason that can cause pain is muscle and nerve damage. Respiratory and limb muscle dysfunction can be caused by several different mechanisms, such as chronic lack of oxygen in the blood, inflammatory, and oxidative stress in the muscle; chronic corticosteroid administration; physical inactivity; ageing; and malnutrition . These cDeconditioningDeconditioning or the reduced functional capacity of the musculoskeletal system can develop due to the disease. As IPF progresses, more and more of the lung tissue becomes scarred. The increased scarring leads to increased shortness of breath or breathlessness during activity. Patients naturally reduce their activity level and become deconditioned over time. Avoiding physical activities that provoke dyspnea and fatigue may be an important key factor of physical deconditioning and exercise intolerance . This caApplication of glucocorticoidsGuidelines recommend high-dose corticosteroid treatment in patients with acute exacerbations of IPF, despite unproven benefit , 40. SomOther painful conditionsSome people diagnosed with IPF may experience pain due to other coexisting medical conditions, such as arthritis. Sometimes, digital clubbing  can be painful to some patients. Digital clubbing occurs due to a chronic lack of oxygen in the blood . The preChronic pain has biological, psychological, and societal consequences. IPF patients who suffer from chronic pain, like any other chronic pain patient, may be more prone to illness and injury, as well as depression, anxiety, and social isolation; all of which contribute to a lower quality of life . Pain caIn everyday clinical practice, patients may not associate musculoskeletal pain with their lung disease, so they may not report this symptom to their physician. Thus, clinicians should be encouraged to be more vigilant in asking patients about all symptoms, including pain, during examinations. Early detection, assessment, and treatment of symptoms related to disease progression, such as pain, are important. Palliative care can provide relief from the painful symptoms and stress that goes along with having IPF and can help improve quality of life of patients and their families , 4. A vaThere is no therapy that is specifically designed to treat pain in IPF patients. The majority of treatments target other pain-related symptoms of IPF, such as cough, manage comorbidities that are associated with pain, or standard analgesics are used .Coughing reduction treatmentsWhen cough is present in IPF, it is severe and difficult to treat as it is often refractory . Cough tLow doses of morphineOpioids have been shown to be effective in reducing intensity of pain in a variety of chronic pain conditions . IndividNSAIDs and paracetamolNon-steroidal anti-inflammatory drugs are commonly used to treat mild-to-moderate musculoskeletal pain . They alGlucocorticoidsCurrently, there is no evidence to support the use of high-dose steroids . When coThalidomideThalidomide has been shown to reduce cough in IPF patients. This drug has anti-inflammatory and antiangiogenic effects, similar to currently used anti-fibrotic drugs , but witSupplemental oxygen therapyAs previously speculated, hypoxia that occurs during the course of IPF may lead to musculoskeletal pain in these patients. Therefore, supplemental oxygen therapy may alleviate pain in IPF patients . There aGiven that pharmacological treatments for the management of pain in IPF patients are very limited, and often ineffective, non-pharmacologic interventions serve as an important therapeutic tool for symptomatic management. The most important non-pharmacological option is pulmonary rehabilitation, but other methods may be beneficial.Pulmonary rehabilitationPulmonary rehabilitation is recommended in the IPF guidelines as a possible supportive therapy . The maiExercise training is an important part of pulmonary rehabilitation in IPF, since it improves exercise performance and overall health . SkeletaExercise training may be challenging to implement in IPF due to severe signs and symptoms experienced by the patients, particularly during exercise. Accordingly, several studies found that mild-moderate IPF patients adapted better to exercise training programs than severe IPF patients . TherefoInterventional exercise training studies in IPF exhibit variability in the training protocols and research methods used . The majThe majority of the studies followed the established COPD guidelines for exercise training in the pulmonary rehabilitation program. These guidelines might be less appropriate for IPF due to different pathophysiological mechanisms of exercise limitation and, therefore, may not provide optimal exercise stimuli and adaptation to training . FurtherOther non-pharmacologic treatment optionsPatient education should be prioritized among other non-pharmacological pain treatments. Patients’ central pain processing can be altered by educating them about pain mechanisms and challenging maladaptive pain cognitions and/or behaviors. The goal of education and cognitive-behavioral therapy is to change beliefs and behaviors that contribute to pain, fear, catastrophizing, and anxiety . Non-phaTo the best of our knowledge, this is the first narrative review that had addressed musculoskeletal pain in IPF patients. We could not find any original research that focused only on pain in these patients, as well. Musculoskeletal pain, on the other hand, is reported by one-third to two-thirds of IPF patients, indicating that it is a clearly understudied and underestimated problem. Alleviating symptoms and improving HR-QoL in IPF are often major challenges to treating clinicians. Because current therapeutic options are limited, patients with IPF require multidisciplinary care that includes disease education, communication, symptom management, and supportive care. Non-pharmacological interventions, such as pulmonary rehabilitation, present the cornerstone for symptom management. Pharmacological therapies (medications) can also alleviate severe symptoms, such as dyspnea, cough, and pain, but there is no single agent that is specifically designed to treat pain in IPF. Another point to emphasize is the presence of comorbidities, which can influence symptoms and should be considered for pain treatment. Further research is needed to get a better estimate of the prevalence, underlying mechanisms, severity, and pain predictors in IPF, as well as the pharmacological and non-pharmacological treatment options.The authors report no conflict of interest.There was no funding involved.Svetlana Kašiković Lečić, MD, PhD, is an internal medicine specialist and pulmonologist in the Institute for Pulmonary Diseases of Vojvodina, Sremska Kamenica, Serbia, and an associate professor in the Dept. of Internal Medicine, University of Novi Sad, Serbia.Jovan Javorac, MD, PhD Candidate, is an internal medicine resident in the Institute for Pulmonary Diseases of Vojvodina, Sremska Kamenica, Serbia, an associate researcher in the Dept. of Internal Medicine, University of Novi Sad, Serbia, and a teaching assistant in the Dept. of Biomedical Sciences, College of Vocational Studies for the Education of Preschool Teachers and Sports Trainers, Subotica, Serbia.Dejan Živanović, RN, PhD, is a clinical nursing specialist and teaching assistant in the Dept. of Biomedical Sciences, College of Vocational Studies for the Education of Preschool Teachers and Sports Trainers, Subotica, Serbia.Aleksandra Lovrenski, MD, PhD, is a pathologist in the Institute for Pulmonary Diseases of Vojvodina, Sremska Kamenica, Serbia, and an assistant professor in the Dept. of Pathology, University of Novi Sad, Serbia.Dragana Tegeltija, MD, PhD, is a pathologist in the Institute for Pulmonary Diseases of Vojvodina, Sremska Kamenica, Serbia, and an assistant professor in the Dept. of Pathology, University of Novi Sad, Serbia.Jelena Zvekić Svorcan, MD, PhD, is a physical medicine and rehabilitation specialist and rheumatologist in the Special Hospital for Rheumatic Diseases, Novi Sad, Serbia, and an assistant professor in the Dept. of Medical Rehabilitation, University of Novi Sad, Serbia.Jadranka Maksimović, MD, PhD, is an epidemiologist in the Institute of Epidemiology, Belgrade, and an associate professor in the Faculty of Medicine, University of Belgrade, Belgrade, Serbia.https://orcid.org/0000-0002-4151-6121Svetlana Kašiković Lečić https://orcid.org/0000-0002-8567-8974Jovan Javorac https://orcid.org/0000-0001-8232-9368Dejan Živanović https://orcid.org/0000-0002-5278-6194Aleksandra Lovrenski https://orcid.org/0000-0002-9269-6644Dragana Tegeltija https://orcid.org/0000-0002-3489-4351Jelena Zvekić Svorcan https://orcid.org/0000-0002-8215-7399Jadranka Maksimović


In some trigger finger patients, tenderness is found in the dorsal proximal interphalangeal (PIP) joint. The etiology and prevalence of this condition are unclear. Furthermore, surgical outcomes for trigger fingers with coexisting dorsal PIP tenderness have not been reported. This study (1) determined the prevalence and risk factors for PIP joint tenderness in trigger fingers and (2) compared postoperative outcomes for trigger fingers with and without joint tenderness.This prospective cohort study was conducted between August 2018 and March 2020. We enrolled 190 patients diagnosed with single-digit trigger fingers undergoing open A1 pulley release. The incidence, demographic data, and surgical outcomes of patients with dorsal PIP tenderness were investigated. Factors associated with tenderness were analyzed, including patient occupation, finger involvement, trigger finger grading, duration of symptoms, previous corticosteroid injections, and presence of diabetes mellitus. A numeric pain scale, a patient-specific functional scale, and the range of motion were evaluated preoperatively and 1, 2, and 6 weeks after surgery, with telephone follow-ups at 3 and 6 months.Of 190 patients, 46.8% had tenderness of the dorsal PIP joint. Patients with joint tenderness had significantly more overall postoperative pain for up to 6 weeks and reported residual minor pain for up to 3 months. The functional scale and range of motion of the 2 groups did not differ during follow-up. The only risk factor observed was the occupation of the patients.Dorsal PIP tenderness is more common in trigger fingers than previously thought. It is also associated with higher and prolonged levels of postoperative pain after A1 pulley release. Therefore, patients with pre-existing PIP tenderness should be informed about the possibility of sustaining residual minor pain for up to 3 months after surgery.II Trigger finger, or stenosing flexor tenosynovitis, is one of the most common hand problems. The condition is characterized by painful locking or catching when flexing or extending the finger or by thumb motion, followed by a disability of hand function . PatholoIn 2018, Kim and colleagues first reported the clinical significance of PIP joint pain in patients with trigger fingers. Their research found 24% of patients with trigger fingers had preoperative PIP joint pain, but only 13% had PIP tenderness. Furthermore, 40% of their patients with trigger fingers reported unsatisfactory outcomes after surgical treatment. The researchers suggested that the pathology of PIP joint pain may be related to a long duration of symptoms and the consequent joint pathology, including synovitis, joint contracture, or arthrosis [This study had 2 objectives. The first was to determine the prevalence and risk factors for tenderness of the PIP joint in trigger fingers. The second objective was to compare the postoperative outcomes for the trigger fingers with and without dorsal PIP joint tenderness in terms of postoperative pain, hand function, and range of motion (ROM).After receiving institutional review board approval, this prospective cohort study was conducted between August 2018 and March 2020. Patients were enrolled if they were 18 years or older, diagnosed with idiopathic trigger finger, and scheduled for open A1 pulley release. All eligible patients consented to participate.Exclusion criteria were revision surgery, inflammatory joint disease, congenital trigger finger, finger deformity or fixed flexion contracture not consistent with trigger finger, history of fracture or tendon injury, and evidence of osteoarthritic changes or deformity in the affected finger on plain radiography. Patients were also excluded if they received simultaneous additional surgery on the ipsilateral hand , had a known allergy to paracetamol or codeine (postoperative pain rescue protocol), or developed a surgical wound infection. We estimated the sample size requirements for detecting the effect size of different of the primary outcomes (pain at postoperative 2 weeks) between two groups by using the G*power program (G*Power version 3.1.9.7). The expected effect size was set at 0.5 with 90% statistical power with a significance level of 0.05. With an expected 10% drop-out rate, a total of 190 patients (95 patients per group) were required, however, 89 patients with PIP tenderness were enrolled in this study.PIP joint tenderness was assessed by pressing on the dorsum of the PIP joint of the affected finger and comparing it with the response of the contralateral finger. “PIP joint tenderness” was defined as pain or discomfort compared to the unaffected finger. Synovitis of the PIP joint was assessed preoperatively using ultrasonography. It was performed by a musculoskeletal radiologist on 52 patients with tenderness of the PIP joint.The patient data collected were age, sex, diabetes mellitus status, occupation, hand dominance, duration of the disease, and history of corticosteroid use. In addition, the swelling and flexion contracture of the affected finger were evaluated. Preoperative classification of triggering was used for grading into 4 categories. They were grade I (“pre-triggering”: pain but no catching); grade II  [Patients were asked to evaluate the extent of pain using an 11-point numeric pain scale (NPS). Ratings ranged from 0 (“no pain whatsoever”) to 10 (“the most intolerable pain”). Various pain measurements of the affected finger were evaluated: pain at rest, pain during finger motion, pain in the A1 pulley, pain at the surgical wound, and pain in the PIP joint.The ROMs of the metacarpophalangeal and PIP joints of the involved finger were measured with a finger goniometer. This instrument is designed to measure the arc or ROM of a particular joint.The patient-specific functional scale (PSFS) requires patients to choose 3 daily activities they find difficult to perform or for which they are unable to complete a particular movement of the affected hand. Patients were asked to rate the difficulty on a scale from 0 to 10. A score of 0 represented an inability (or much difficulty) to perform the simple daily task, whereas a score of 10 signified ease of motion or no difficulty. The scores for the 3 activities were then summed and averaged for each patient .Postoperative NPS scores, ROM, and PSFS scores were obtained at 1-week, 2-week, and 6-week follow-ups. At 3 and 6 months, the NPS and PSFS scores were obtained by telephone. All examinations and measurements were collected and assessed by a single trained technician.The patients were treated with open A1 pulley release under local anesthesia with 1% lidocaine. Operations were performed by any one of several orthopedic surgeons at the study center using the same technique. The A1 pulley was completely transected by a transverse or oblique skin incision, after which the intraoperative active finger flexion was evaluated. Postoperative pain was managed with paracetamol with codeine (300 mg of paracetamol and 15 mg of codeine), and the amount required was recorded. Any additional analgesics that the patients needed were also noted. Suture removal was performed 2 weeks after surgery in most cases.t-test was used to determine the difference between groups. Categorical variables were presented as frequencies and percentages and compared by the chi-squared test or the Fisher exact test. Univariate and multivariate logistic regression analyses were created to determine factors associated with PIP tenderness. Repeated measurements  were analyzed using a linear mixed model, including all pre- and postoperative time points. Time was included as a repeated effect with an unconstructed covariance structure. Between groups (with or without PIP tenderness), time and the interaction group × time were set as fixed effects. The p-values < 0.05 were considered statistically significant. Due to some possible violation of normality assumptions, the Mann–Whitney test was used for sensitivity analysis for the significantly different functional outcomes between groups. However, as no different results were observed, these data are not reported. The p-values < 0.05 were considered statistically significant. For repeated measurement, the p-value was adjusted with the Bonferroni method by multiplying by the number of tests. All statistical analyses were performed using IBM SPSS Statistics for Windows, Version 23.0 .Demographic and clinical data were summarized with descriptive statistics and compared. Continuous data were assessed for normality with the Kolmogorov–Smirnov test. Normally distributed continuous variables were presented as means and 95% confidence interval, and an independent Of the 190 participants, 89 (47%) had dorsal PIP joint tenderness. Table P = 0.002). Among 89 patients with PIP joint tenderness, 52 underwent ultrasound examination to evaluate synovitis of the PIP joint. Only 2 of the 52 patients (3.8%) had a positive sign of synovitis.Moreover, no statistical differences were observed between the 2 groups regarding age, sex, disease duration, history of corticosteroid use, affected finger, trigger finger grading, or whether the affected finger was on the dominant hand. Diabetes mellitus was equally distributed in both groups. The long and middle fingers were the most affected in both groups (41.6%). PIP joint swelling was found significantly more frequently among patients with PIP joint tenderness . At the second postoperative week, although there was a statistically significant higher rest pain level for the PIP tenderness group, the pain levels for both groups were subtle (mean NPS score of both groups < 1).P < 0.05). The PSFS score, total arc of motion, and PIP extension also improved gradually over the follow-up period, but without statistical difference between the patients with or without PIP tenderness. The postoperative range of motion was not affected by coexisting PIP tenderness. However, patients with PIP tenderness had a slight loss of PIP extension and lower PSFS score at 2 weeks after surgery.The overall motion pain significantly decreased for both groups during the postoperative period, although with a substantially higher pain score for the PIP tenderness group during the initial 2-week follow-up period (P < 0.05). However, only overall digit pain revealed a significant difference between groups and found an interaction between time and PIP tenderness (P < 0.05). At the 6-week follow-up, the mean motion pain score for the PIP tenderness group was 1.9 compared with 1.3 for patients without PIP tenderness, it might not be clinically significant. However, we found that 16 patients (18%) with PIP tenderness reported persistently significant pain (mean NPS score > 3) during digit motion, compared with only approximately 8% of the patient without PIP tenderness . Although almost all pain had subsided by 3 months postoperatively in both groups, approximately half of the patients with PIP tenderness (48.3%) and only one-third of the patients without PIP tenderness complained of residual minor pain on digit motion .The time, between-group, and interaction effects on functional outcomes were analyzed using a linear mixed model and are summarized in Table Pain and stiffness around the PIP joint are among the most significant clinical findings in trigger finger pathology. In a 2018 study, Kim and coauthors reported that 24% of 179 patients exhibited PIP joint pain concurrently with prolonged symptoms of trigger finger, fixed extension loss, and joint tenderness. Postoperatively, these patients had higher pain scores and considerable dissatisfaction with the recovery process at a mean follow-up of 18 months. However, the etiology of the PIP joint pain was unknown . PossiblThe current work focused on dorsal PIP tenderness and found that 46.8% of patients with trigger fingers had coexisting dorsal PIP joint tenderness. Unlike the report by Kim et al., we did not find a correlation between tenderness and either symptom duration or fixed extension loss. The mean duration of the symptoms found by Kim and associates was approximately 23 months. This period was markedly longer than that of our study (8 months), and it may be one of the explanations for the different results. In addition, the research by Kim and colleagues investigated PIP joint pain. In comparison, our study examined dorsal PIP tenderness, which accounted for only 13% of their patients [The patient demographic data associated with PIP joint tenderness were not impressive in terms of severity, duration of symptoms, age, sex, or diabetes. The only exception was the occupation variable. Self-employed or light manual workers more frequently had coexisting PIP tenderness than homemakers, office workers, and retired or unemployed patients.We found that dorsal PIP joint tenderness was associated with poorer surgical outcomes for the trigger fingers. Patients with tenderness had higher rest and motion pain scores before surgery and for up to 6 weeks after the procedure. Additionally, more patients with PIP tenderness still had pain scores > 3 at the 6-week follow-up and reported residual minor pain on digit motion for up to 3 months after the operation.Coexisting joint pathology may be associated with poorer postoperative results due to another risk factor , 7. For The pathogenesis of dorsal PIP tenderness in patients with trigger fingers has not yet been established. Synovitis of the PIP joint might not be a significant cause as only 2 of the 52 patients with PIP tenderness had a positive sign of synovitis detected by ultrasonography. The ultrasonographic features of trigger fingers demonstrated by Chuang et al.  suggesteMany other confounders can affect postoperative outcomes. For example, Cakmak and colleagues found that light manual workers had significantly longer postoperative symptoms. Patients with preoperative systemic steroids and trigger thumbs recovered faster . Baek etThe current study controlled specific factors to identify the influence of coexisting dorsal PIP tenderness on surgical outcomes. They were age, sex, associated diseases, disease duration, severity, and use of steroids and nonsteroidal anti-inflammatory drugs. The surgical operations in the study were conducted in the same surgical suite, and the surgeons used the same technique throughout the study to avoid potential confounder effects related to the operation.A possible limitation of this study was that the same surgeon did not perform the surgical intervention. However, all patients were assigned to the same surgical suite, so it can be assumed that the operative technique of open A1 pulley release was similar in all cases.Dorsal PIP tenderness is more common in trigger fingers than previously thought. It is also associated with higher and prolonged postoperative pain after A1 pulley release. Therefore, patients with pre-existing PIP tenderness should be informed about the possibility of sustaining residual minor pain for up to 3 months after surgery.