The aim of this study was to compare the short-term outcomes between 2 different treatments for unilateral chronic shoulder pain of myofascial origin, that is, local tender area related meridians (LTARMs) treatment and collateral meridian therapy (CMT), which were performed 6 times over a period of 4 weeks.Seventy patients with unilateral shoulder pain of chronic myofascial origin were enrolled. The patients were randomly assigned to 2 different treatment groups: 1 group received CMT (n = 35) and the other received LTARM (n = 35). Before and after the 2 treatment processes, all patients rated their overall pain intensity on a visual analogue scale (VAS) and a validated 13-question shoulder pain and disability index (SPADI) questionnaire was used to measure shoulder pain and functional impairment after therapy for 4 weeks.P < 0.005; SPADI pain subscale score from 0.58 ± 0.16 to 0.45 ± 0.14, P < 0.001). In addition, the VAS scores of patients changed considerably in the CMT group after 4 weeks of treatment, where 63% of patients felt no or mild pain, whereas the VAS scores for moderate pain were even higher in the LTARM group in 75% of patients (P < 0.001). Moreover, the SPADI disability subscale scores improved significantly in the CMT group because of their greater mobility associated with shoulder impairment (disability score: from 0.58 ± 0.20 to 0.35 ± 0.14) than those in the LTARM group .After CMT, the pain intensity was reduced after CMT. VAS score is reduced from 5.90 ± 2.07 (a mean of 5.90 and standard deviation of 2.07) to 3.39 ± 1.2. This was verified by the SPADI pain subscale scores (from 0.58 ± 0.193 to 0.33 ± 0.14). The pain-relief effect of CMT was significantly better than that of LTARM (VAS score from 5.78 ± 1.64 to 4.58 ± 1.40; CMT may be more effective in reducing chronic shoulder pain of myofascial origin than the LTARM treatment, where treatment with the former resulted in better functional recovery after 4 weeks than the latter. There are no gold standard criteria for shoulder pain diagnosis, and thus significant differences in prevalence (from 6.9% to 26%) have been noted. Various treatments for shoulder pain of myofascial origin have been reviewed, including dry needle, acupuncture, multimodal treatment, low-level laser therapy, and fascial manipulation. In general, these are local treatments that focus on the affected region and they are only moderately effective in improving the function of the painful shoulder and reducing pain. Collateral meridian therapy (CMT) is a recently developed technique derived from traditional Chinese medicine, but it differs considerably from traditional Chinese acupuncture. In particular, CMT is a 2-point manipulation technique that involves operations on the control point (C-point) and the functional point (F-point) located in relevant healthy meridians, which are distal to the associated disease-related meridians. Thus, CMT redirects, removes, reduces, or strengthens the body energy flows (“Qi”) to achieve pain relief and to restore homogeneity.Shoulder pain is a considerable burden on patients and their families,,12 In the latter study, we showed that CMT was even more effective than acupressure on the local tender area.An important characteristic of CMT is that it is usually applied to distal acupoints or meridians located away from the lesion site, and clinically, CMT appears to be more effective than direct local acupressure or treatment of the affected meridian alone. Previously, we have successfully applied CMT to treat musculoskeletal pain, such as postregional anesthesia/analgesia backache and postlaparoscopic shoulder-tip pain.In the present pilot study, we compared 2 treatments for unilateral chronic shoulder pain of myofascial origin, that is, local tender area related meridians (LTARMs) treatment and CMT for a period of 4 weeks. We performed evaluations to determine which was the most effective for shoulder pain relief and functional recovery.22.1We received approval from Tri-Service General Hospital institutional review board (TSGHIRB No: 98-04-002) and performed in compliance with the Helsinki Declaration. The patients were outpatients at pain clinics and rehabilitation division in the Tri-Service General Hospital, Taiwan. All patients were examined according to a standardized assessment process to ensure that their pain was musculoskeletal in origin. After careful evaluation, including physical examinations, X-ray, and sonography of shoulder joints, patients aged between 20 and 65 years who had complained of unilateral shoulder pains for at least 3 months were included in the study. All participants were asked not to take pain-killers for at least 1 week before the study, as well as during the study period. Those who refused or failed to do so were excluded. Over the course of the trial, investigator-supplied paracetamol was the only pain-killer allowed for additional pain relief. Patients with the following conditions were also excluded from our study: cervical neuropathy/surgery or peripheral neuropathy; bone fractures; unstable joints/impingement syndrome; contraindications that excluded acupuncture or electrical stimulation, such as pregnancy and cardiac pacemakers; partial or full-thickness tear of rotator cuff; significant impairment of sensation; or fibromyalgia.Before the enrollment, the patients were informed that there were 2 commonly applied meridian therapies, viz. CMT and LTARM, and that both were effective methods in relieving chronic pain. But there was no hint whatsoever as to which might be a better treatment than the other. The patients were informed that they would undergo meridian therapies for chronic shoulder pain, but they had no idea whether they received CMT or LTARM, as both procedures involved using an electrotherapy stimulator, attaching electrodes to certain areas, and/or acupoints of the patients. For the participants, there was no distinguishing between the 2 therapeutic processes. Using a computer-based randomization program, patients were allocated at random to either the CMT or LTARM groups. All participants were asked not to reveal their therapeutic details to the research assistant, and they were not aware that they would be which one therapeutic group. An independent research assistant who was engrossed in the study and remained “blind” to group allocation executed outcome assessments. The patients, research assistant, and the statistical analysts who reviewed the outcome were all blinded to the group assignments.2.2All of the treatment procedures for the 2 groups were prescribed by the same pain specialist well-trained in CMT advanced course. All subjects were treated in a supine or sitting position. In the CMT group, the specialist diagnosed the disease meridians in the affected shoulder and wrote 2-step prescriptions. The treatment procedures were conducted by a well-trained nurse, who was prohibited not to reveal any therapeutic information to the participants, using an ENRAC electrotherapy stimulator  for about 60 minutes in a 2-step maneuver, that is, maneuver A  questionnaire was completed to measure shoulder pain and functional impairment by a research assistant, who was blinded to the exact treatment procedures.,15Before and after 4 weeks of therapy (6 times), all of the patients were asked to rate their pain on a visual analogue scale (VAS) and a questionnaire was also completed. The VAS score assessed the overall pain intensity,2.4t tests were used to compare differences in age, height, weight, and duration of pain between patients who received CMT therapy and LTARM therapy. We performed Chi-square tests to explore differences in variables related to sex between patients who received CMT therapy and LTARM therapy. In addition, independent t tests were conducted to compare differences in the overall VAS scores between patients who received CMT therapy and LTARM therapy. Furthermore, a Chi-square test was used to compare differences in pain levels between patients who received CMT therapy and LTARM therapy at baseline and after 4 weeks. Finally, we used independent t tests to compare the differences in SPADI ratings between patients who received CMT therapy and LTARM therapy at baseline and after 4 weeks. Differences were considered significant for 2-sided P values <0.05.The statistical analyst was blinded to both the subjects and the investigators. The statistical analyses were performed using the Statistical Package for the Social Sciences . Independent 3P < 0.001). Table P < 0.01), 0.35 ± 0.14 versus 0.44 ± 0.14 (P < 0.05), and 0.34 ± 0.14 versus 0.44 ± 0.14 (P < 0.01) for the CMT and LTARM groups, respectively. For both groups of patients, no treatment-associated adverse effects were reported during the whole course of the study.In total, we assessed 120 patients for eligibility and 70 patients were enrolled to the study. These patients were randomly assigned to the CMT and LTARM groups, with 35 patients in each group. Subsequently, 8 of these 70 patients withdrew from the study, and thus, 62 patients qualified for the study in the end. Figure 4 Many published CMT clinical reports have described the application of acupressure to treat various types of acute and chronic pains, such as dysmenorrhea and complex regional pain syndrome.,17 However, to the best of our knowledge, only 1 previous study has described the application of EES for CMT, which focused on the effectiveness of EES in improving knee osteoarthritis pain and knee function. In our study, we demonstrated that by applying the technique with EES, CMT was more effective than LTARM for reducing shoulder pain of chronic myofascial origin.CMT provides an alternative for the treatment of different types of pain by using a systematic approach based on a variant of traditional Chinese acupuncture. CMT involves the manipulation of multiple sets of acupoints to relieve pain according to structured formulae using various techniques and tools, such as acupressure and EES. dry needle, electroacupuncture, and transcutaneous electrical nerve stimulation (TENS).,22 A common feature of these techniques is direct manipulation of the lesion site. All of these techniques have been used with varying degrees of success in the management of chronic shoulder pain. In a review, Chen and Wang showed that acupressure can reduce various types of pain, including dysmenorrhea, labor pain, lower back pain, chronic headache, and other traumatic pains. However, few if any previous studies have focused on the effectiveness of acupressure in treating shoulder pain. In particular, Chen and Wang aimed to establish a credible evidence base for the use of acupressure in treating various types of pain, but shoulder pain relief was conspicuously absent from their systematic review. However, numerous clinical case reports have shown that CMT is effective in pain management.–12,16–18 For example, we successfully treated postlaparoscopic shoulder tip-pain with CMT by employing the acupressure technique. In the present study, we investigated the efficacy of CMT by applying the EES technique to treat chronic shoulder pain of myofascial origin, which we compared with the effects of LTARM.Various noninvasive or minimally invasive techniques can be used for treating chronic shoulder pain, such as acupressure,,20–22 Compared with manual needling, electroacupuncture is a modern approach based on clinical and basic scientific evidence, which has advantages in terms of time savings and high reproducibility. Wang et al showed that acupoint stimulation by electroacupuncture or TEAS may have a similar therapeutic effect and underlying mechanism. In particular, it is considered that like electroacupuncture, TEAS can lead to a significant increase in analgesia by inducing the release of endogenous opioids.,25 The tailor-made modality designed for CMT clinical application by our study group, which involves the application of EES to distal acupoints, can be considered as a modification of TEAS. Thus, it is possible that the underlying mechanism of CMT is at least partially similar to that of TEAS and electroacupuncture.In clinical practice, various techniques have been used to ensure the optimal stimulation of acupoints, such as acupuncture, electroacupuncture, and transcutaneous electric acupoint stimulation (TEAS). Therefore, in our control group, EES could also be considered as a variant of TENS when applied directly to the affected areas. In our study, we compared local EES (in the LTARM group) and distal EES (in the CMT group), and both were shown to be analgesic, but the pain-relief effect was significantly better in the CMT group  than that in the LTARM group. In terms of possible explanations, other mechanisms may be involved in addition to the “gate control” theory. Thus, the following hypothesis may be proposed. The mechanism known as diffuse noxious inhibitory control can modulate pain at a distance from the site of stimulation. It is possible that when producing peripheral stimulation, CMT might trigger a descending inhibition system that originates from the brainstem structures.,28TENS is a form of noninvasive electrical stimulation that has been applied widely to treat various acute and chronic musculoskeletal pains via direct manipulation on painful areas. TENS evokes nonpainful electrical counter-stimulation via the afferent Aβ fibers and this “gate control” mechanism may interfere with nociception transmission to achieve an analgesic effect.,30 In the CMT treatment, EES stimulates the distal healthy meridian to relieve shoulder pain. In other words, the stagnation of Qi is allowed to flow from the site of pain to the unobstructed or healthy meridian, thereby leading to the dissipation of shoulder pain. The C-point links the diseased meridian and treatment meridian, while the F-point is used for the treatment of the disease-associated symptoms or painful areas. By stimulating the C-point and F-point on a healthy meridian using acupressure, acupuncture, or EES, we can redirect the obstructed Qi from the diseased meridians in the painful regions to the aforementioned healthy meridian.According to the theory of traditional Chinese medicine, pain is a result of blood stasis due to Qi stagnation . found that in patients who underwent multiple acupuncture sessions, the benefit of short-term pain relief and functional improvement might have been partly attributable to the so-called placebo effect. Similarly, the pain-alleviating effect attributed to EES in both groups may have been related to the specific and nonspecific effects of the therapeutic session, but we did not attempt to differentiate between these components in this study. Although it is debatable, some researchers have demonstrated that TENS has a placebo effect in reducing the overall pain intensity by about 20% to 30%.,31 Moreover, this study specifically blinded the patients to their treatment. The reason for which they were blinded is to lower their bias in favor of the CMT treatment, thus eliminating the placebo effect in the overall study. Also, another more important reason is to distinguish which treatment is more effective between CMT and LTARM. However, due to methodological factors associated with the blinding of patients, it is difficult to distinguish the effects of TENS from the placebo effect. In our study, it was difficult to eliminate the possibility of placebo analgesia or to determine its level when applying EES to both groups.Zheng et al4.1–34 In the worst case scenario, arranging a sham group would have put the patients under risk of unexpected adverse effects from long-term persistent pain. Finally, it would be desirable to conduct larger scale clinical trials to follow up the median or long-term effects of CMT in the future.Our study had some limitations. First, all of the treatment procedures were prescribed by the same pain physician, so they were not double-blinded. However, we did exclude the physician from reviewing the outcomes, thereby single blinding the study. Second, the nonstandardized physical and daily activities of the patients might have affected the outcomes during the treatment period. Third, there was no sham group in our study, which made it difficult to address the possible issue of a placebo effect. It is known that sham therapy may be as efficacious as real therapy, or it may produce some degree of placebo effect, or no effect at all.5The current study demonstrated that CMT may be a more effective therapeutic option than LTARM for reducing chronic shoulder pain of myofascial origin in patients, where CMT achieved better functional recovery after 6 sessions over 4 weeks. Thus, on the basis of our results, CMT can be regarded as a special form of peripheral stimulation that achieves a neuromodulation effect. It may provide health care professionals with a noninvasive treatment modality to relieve chronic shoulder pain of myofascial origin, which can be utilized in addition to medications and physical therapy.


Background The open preperitoneal repair offers the benefits of placing the mesh in the preferred position while avoiding the disadvantages of laparoscopic repair.Methods A total of 60 patients with bilateral inguinal hernias were randomized to undergo either the standard Lichtenstein meshplasty or the modified iliopubic tract repair in a teaching hospital. Outcomes measured were immediate postoperative pain, return to activity, and delayed neurological complications.Results Patients who underwent the iliopubic tract repair walked out of bed faster than the Lichtenstein group  and experienced significant lower pain as charted by visual analogue scale scores . Delayed complications like chronic inguinal pain and numbness were not seen in the iliopubic tract group. However, this difference was not statistically significant (p > 0.05).Conclusion The iliopubic tract repair offers an excellent alternative to the Lichtenstein meshplasty, and is associated with lower postoperative pain, earlier return to work, and lower delayed neurological complications. A few surgical conditions can boast of such a multitude of management options as inguinal hernias. The surgeon of today has a vast range of surgical techniques at his disposal, ranging from anatomical repairs to the modern laparoscopic repairs. Among these, the modified Lichtenstein meshplasty remains the most popular. This popularity can be attributed to its ease of learning, safety, and low recurrence rates.This technique is not without its drawbacks. Postoperative pain, numbness, and chronic groin pain continue to plague patients following meshplasty. The former can be attributed to the greater number of nerves encountered during the anterior approach used in the Lichtenstein technique.The open preperitoneal approach has the advantage of placing the mesh in the preferred location, namely, the preperitoneal space, while eschewing the problems associated with laparoscopy.This study compared a modification of the iliopubic tract repair, wherein a single midline incision is used for bilateral repair, to the standard Lichtenstein meshplasty with respect to postoperative pain, time taken to return to work, and neurological complications (chronic groin pain and numbness).A prospective randomized study of 60 patients was performed at our hospital between May 2015 and May 2017. The study protocol followed the guidelines stated by the CONSORT criteria. The sample size was calculated using the formula:n = z2xP(100–P)/d2Where:Pwas the anticipated prevalencedwas the desired precisionzwas the appropriate value from the normal distribution for the desired confidence, which was 95% in our study (z = 1.960).Demographic details of all patients were recorded. Patients between ages 18 and 80, with bilateral uncomplicated inguinal hernias, were randomized into two groups: one undergoing the Lichtenstein meshplasty, and the other, the modified iliopubic tract repair. Patients with unilateral, complicated, congenital, and recurrent hernias were excluded from the study Institute Ethics Committee clearance was obtained prior to initiation of the study. Informed consent was obtained from all patients after explaining the nature of the study, and the advantages and disadvantages associated with both procedures.All the patients in the study were operated upon by the same team of surgeons comprising experienced consultants, as well as surgery residents.Both groups received inj. cefotaxime 1 g intravenously (IV) at the time of induction of anesthesia as per our institute protocol.Patients in Group A underwent the standard Lichtenstein meshplasty repair as described in literature. A 3”x 6” lightweight Prolene mesh was fixed over the posterior wall of the inguinal canal using interrupted Prolene sutures, and the procedure repeated on the opposite side after repair of one side.Patients in Group B underwent the modified iliopubic tract repair, wherein the preperitoneal space was accessed using a lower midline incision, extending from below the umbilicus to the pubic symphysis. The hernia sac was then identified. In case of indirect inguinal hernia, the sac was ligated and divided at the level of the deep ring, with the distal part of the sac remaining within the canal. In case of a direct hernia, the sac was inverted with a running purse-string suture. Repair was then done by approximating the arching fibers of the transversalis fascia superiorly to the iliopubic tract  inferioBoth groups received inj. cefotaxime 1 g IV 12 hourly for 3 days as per institute protocol for antibiotic prophylaxis, and inj. paracetamol 1 g IV 8 hourly for analgesia postoperatively.Main outcome assessed was postoperative pain, with time taken to walk out of bed, long-term pain, and numbness being secondary outcomes assessed.Patients were assessed immediately postoperatively for pain. Pain was charted using the 10-point numerical visual analogue scale (VAS) every 8 hours until discharge. Time taken to walk out of bed was defined as the time taken for the patient to independently stand and walk out of bed.Patients were additionally followed up 3 monthly, for a period of up to 2 years. They were asked about inguinal pain and history of consuming analgesics. Patient were also subjected to a physical examination to assess numbness and paraesthesia. Follow-up examinations were conducted by a member of the team who was not the operating surgeon for the particular case to avoid bias.t-test. Apvalue less than 0.05 was considered statistically significant.Tabulated VAS scores were assessed for significance using the Mann–Whitney U test. Time taken to walk out of bed, and chronic pain was compared using the unpairedAll 60  patients completed the study. None were lost to follow-up .pvalue = 0.49). All patients in the study were males.Majority of the patients were in the 61 to 70 years bracket . The youngest patient in the study was 24 years old, while the oldest was 80 years old. Both groups were comparable, with no statistical difference in age (p < 0.0001) . This difference was significant at 95% confidence interval (0.0001) .p < 0.05). Difference in pain was not significant on days 4 and 5 (p > 0.05) (Patients in the Lichtenstein group had higher VAS pain scores postoperatively compared with the iliopubic tract repair group up to the third post-op day (> 0.05) p > 0.05)  as compared with the iliopubic tract repair group. However, this difference was statistically insignificant (> 0.05) .The ideal method of hernia repair would cause minimal discomfort to the patient, both during the surgical procedure and in the postoperative course. It would be technically simple to perform, and easy to learn, would have a low rate of complications and recurrence, and would require only a short period of convalescence.Most modern studies compare the standard Lichtenstein meshplasty to laparoscopic techniques, and few directly compare it to open preperitoneal methods. This makes it difficult to assess the impact of the posterior approach itself in the surgical outcome, factoring in the minimal trauma caused by laparoscopic methods. The present study design makes it possible to directly study the role of the posterior approach alone in outcome of hernia repair by comparing it to the current gold standard.The results can vary widely among different centers, and the results from specialized centers are often good. For example, very low recurrence rates have been reported from the Shouldice Hospital using their eponymous technique, even <1%,The Nyhus repair is considered the standard open preperitoneal repair. Our study focused on our modification of the same, tailored specifically to bilateral inguinal hernias. This choice was also relevant as it considered the cost of the repair, which is sensitive in a developing country like ours.The iliopubic tract repair showed significantly shorter time taken to walk out of bed among patients as compared with the Lichtenstein meshplasty (6.33 hours vs 7.4 hours). Multiple studies also demonstrated the same, clearly giving the open preperitoneal approach the advantage.The most significant advantage for the iliopubic tract group was in terms of postoperative pain. Mean VAS scores for the iliopubic tract repair group following surgery were significant lower than those for the Lichtenstein group in the immediate postoperative period, until the third postoperative day . Mean VAS scores showed no statistical difference toward the end of day 4 and on day 5.Postoperative pain following hernia repair has extensively been studied, and most reports show a distinct advantage with the posterior preperitoneal approach, as employed by the iliopubic tract repair. A meta-analysis of over 500 patients showed significantly higher pain following Lichtenstein repair as compared with preperitoneal repair.Late complications are a bane of hernia repair. Our study assessed patients for groin numbness, chronic pain, recurrence, and late infection at 3 monthly intervals for a maximum period of 2 years. Long-term pain was measured based on a history of analgesic use, and restriction of daily activities. While other indices are available, we found their application difficult with our patients, who mostly are illiterate and come from poor backgrounds. Late complications were encountered more in the Lichtenstein group, with five patients reporting numbness, one each reporting chronic groin pain and recurrence. None of the patients who underwent the iliopubic tract repair suffered any delayed complication. However, this was not statistically significant, and a more extensive study would be required to confirm statistical advantage.Our findings, however, were in contrast to others, who have reported significantly higher rates of groin numbness and chronic inguinal pain among patients undergoing the Lichtenstein meshplasty as compared with preperitoneal repairs. It has been postulated that this may be due to the greater chances of nerve damage in the anterior approach employed by the Lichtenstein repair.The modified iliopubic tract repair has shown several clinically relevant advantages. Patients experienced significantly lower pain after the iliopubic tract repair and walked out of bed faster as well. They also experienced lower rates of neurological complications. Immediate postoperative complications were on par with the high standards set by the Lichtenstein meshplasty.For surgeons who prefer an open approach, the modified iliopubic tract repair is a stellar alternative to the Lichtenstein meshplasty, especially for bilateral and recurrent hernias.


This broad narrative review addresses the relationship between adolescent idiopathic scoliosis (AIS) and back pain. AIS can be responsible for low back pain, particularly major cases. However, a linear relationship between back pain and the magnitude of the deformity cannot be expected for any individual patient. A large number of juvenile patients can remain pain-free. The long-term prognosis is rather benign for many cases and thus a tailored approach to the individual patient seems mandatory. The level of evidence available does not allow stringent recommendations for any of the disorders included in this review. Scoliosis is a frequent pathology in adolescents. Young patients and their families frequently blame (minor) deformities, considered to be the cause of back pain. In our opinion, the relationship between the two is not so clear based on scientific evidence. For this reason, we here review this topic in depth.A high prevalence of low back pain (LBP) among children and adolescents has been identified in the last few decades. A recent systematic review and meta-analysis  has repoTrying to establish a causal relationship between deformities and back pain is not an easy task. Since Sir Austin Bradford Hill  publisheOur aim is to review the literature to evaluate the association in adolescents between back pain and idiopathic scoliosis, reported in studies done in different settings and/or with different perspectives.This paper is the product of the collaboration between 2 clinicians: an orthopaedic surgeon highly focused on deformities (FP) and a rheumatologist with a special interest in juvenile spinal disorders (FB). We have tried to find clinically relevant information that might answer some of the questions the practitioners have. Therefore this article does not aim to be a systematic review as we have not applied strict methodology as recommended, for example, by the Cochrane collaboration, for such reviews. We began with a bibliography search limited to MEDLINE and expanded this body of literature with a search of the publications cited in the selected articles. The search was done using several key words for back pain  as well as for the age category of interest (adolescent OR teenager OR juvenile OR paediatric OR infant OR children). We then limited the search to meta-analyses and expanded it to include “systematic reviews”, and “cohort or longitudinal studies”, if the information gathered was too limited with the most stringent criteria. Our focus was on back pain and consequently the articles not including data on symptoms were excluded except for the http://www.srs.org/professionals/online-education-and-resources/glossary/revised-glossary-of-terms), idiopathic scoliosis can be defined radiographically as a lateral curvature of the spine greater than or equal to 10° Cobb with rotation, of unknown aetiology.According to the glossary of the Scoliosis Research Society (SRS) . For scoliosis, data from 2002 showed the following means in % (girls/boys) for prevalence at 0–14 years of age and at 15–24 years: M41: 2.31 (2.51/2.12) and 3.44 (3.80/3.07) . RamirezA retrospective chart review of a random sample of 310 individuals (10–17 years) selected from all cases of AIS referred to a Canadian university hospital has been published recently . The autp < 0.001) with no significant differences in maximum Cobb angles (F: 53.3° and M: 55.9°) or Risser grades (F: 3.2 and M: 3.5) [A prospective multicentre study including 744 patients  surgically treated for AIS addressed the differences between genders in functional outcome. Before surgery, males were aged an average of 15.2 years and females 14.0 years ( M: 3.5) . At base M: 3.5) .p = 0.038), but is at the limit of the minimum clinically important difference (MCID), reported to be 0.20 [r = 0.103, p < 0.05) [A recent meta-analysis has been published comparing selective versus non-selective thoracic fusion in Lenke 1C curves . Preoper be 0.20 , 25, 26. < 0.05) . Moreove < 0.05) .Other studies have also shown that culture and ethnicity have an influence on outcomes with Caucasians reporting more pain than East Asians on the SRS-30 , 29. Finp < 0.05; however, the differences between the two groups do not seem clinically relevant when compared with the properties of the same tool described elsewhere [The Pediatric Outcomes Data Collection Instrument (PODCI), a multidimensional tool developed in North America  , was uselsewhere .Considering another perspective on the association between symptoms and scoliosis, a study carried out on 1743 men in the military (range: 18–30 years) found a prevalence of idiopathic scoliosis of 6.65 % among those with no symptoms and free of any lytic or olisthetic lesions . Of noteClark et al.  have jusIt appears quite clear from comparing the prevalence of back pain and scoliosis that the latter cannot be the main explanation for LBP for a majority of adolescents reporting such symptoms, although scoliosis playing a role in some patients cannot be ruled out. However, comparing the results of different studies does not allow any firm conclusions to be drawn on the possible causal relationship between different variables. Nevertheless, the compelling and overwhelming predominance of girls in the adolescent cohorts with idiopathic scoliosis  casts dThe main references quoted in this section are summarized in Table In this section, the effects of different treatments on the magnitude of scoliotic curves have not been included. Such an analysis, as well as the impact of treatment in cosmetic, psychological or other issues, would be beyond the scope of this review. Further, long-term follow-up studies in middle-age adults have also not been included, as the role of degenerative changes cannot be identified.Numerous conservative techniques have been used to treat AIS, such as acupuncture, braces, electrical stimulation, exercises, foot orthosis, osteopathy, and yoga. The most recent systematic review on braces for AIS reported long-term stability in terms of back pain  in addition to a similar outcome for quality of life and psychological and cosmetic issues . The autIn a systematic review by Maruyama et al. , bracingThe authors of the most recent Cochrane review comparing surgical and conservative management of adolescent idiopathic scoliosis did not find any papers that would allow drawing conclusions regarding back pain . SeveralOsteopathic manipulative treatments in children were reviewed by Posadzki et al. . Only onIn his recent review paper, Kim  found noA recent systematic review on the effects of exercise in patients with AIS concluded that exercises improve quality of life . The datA recent trial compared an 8-week program of weekly-supervised spinal stabilisation exercises to unsupervised exercises . Pain, eThe beneficial effects of bracing in terms of pain are influenced by compliance with the SOSORT Brace Treatment Management Guidelines (SBTMG) .A recent review of the literature with statistical analysis included 16 cohorts with data on pain. Of these, 81 % reported a statistically significant postoperative (2 years) improvement in pain, however, in only one study were the improvements clinically important . SimilarN = 295) preoperatively, to 68.8 % at 1 year and to 64.4 % at 2 years. Indeed, at follow-up, 40 % of the 295 patients reported a decrease in pain, 38.6 % no change and another 20.3 % reported an increase in pain. Of note, while reported pain decreased with treatment, analgesic use remained unchanged. Reduction in pain and absolute pain at 2 years were both correlated with patients’ perception of deformity, evaluated by means of the SAQ . Such an association might be interpreted as decreasing the likelihood of a major biomechanical role of the deformity to explain pain.A multicentre, prospective, consecutive clinical series reported on the prevalence and predictors of pain in AIS treated surgically . Preoperp = 0.003). Of note, although in absolute values the differences between genders were the same pre- and post-operatively (i.e. 0.2), the pre-operative difference was not statistically significantly [The previously cited multicentre study that included 744 cases treated surgically reported outcomes at 2-years follow-up . The SRSficantly .Akazawa et al.  reportedN = 584 patients) recently reported on the prevalence of postoperative pain and its relationship with preoperative pain [p < 0.001) and clinically significant.A prospective registry based study (ive pain . Patientn = 190 with 2-year follow-up and n = 77 with 5 years follow-up) reported on pain prevalence and trajectories after spinal fusion. Patients were evaluated by means of the SRS-30. Moderate to severe pain in the past month was reported by 35 % of patients preoperatively. The same figure was 11 % at 1-year follow-up and 15 % at 2- and 5-year follow-up. Curiously, medication usage did not change significantly: daily opioid use was reported by 1 % across all time points and weekly or less frequent use of non-opioid medication also remained stable  [Another multi-centred registry study of AIS patients treated surgically (llow-up) .P < 0.0001) but below the MCID. At 2 years, the correlation of the reported pain with the satisfaction score was 0.260, slightly lower than for appearance (0.280) and for the total SRS-22 score (0.398) but higher than for activity (0.172) or mental (0.202) scores.A longitudinal cohort of 745 patients with AIS treated surgically was followed for 2 years and the results of the pre- and postoperative SRS-22 compared . The preWe have identified two further studies comparing the effects of bracing and surgery for the treatment of AIS. A short-term study using the SRS-22 questionnaire evaluated the outcome at age 16.3 ± 1.6 years of 109 Dutch adolescents with AIS treated either by brace, surgery, or brace followed by surgery . The grop = 0.003). The corresponding values obtained with the SRS-24 were 3.8 ± 0.6 and 3.5 ± 0.7 (p = 0.002). Postoperatively, the same questionnaires did not show any significant difference in pain according to neither the percent correction (<40 % Vs ≥80 %) nor when stratifying into post-operative curves <11° or ≥29° [A recent study has shown that both the SRS-22 and SRS-24 questionnaires are able to discriminate between AIS patients with preoperative curves >80° and those <45°. Specifically concerning pain, evaluated by the SRS-22 tool, the scores were 4.2 ± 0.7 for small curves versus 3.8 ± 0.9 for large  correlates with pain (Pearson correlation “r” LSDI versus SRS-22 Pain: −0–749) and functional limitations (LSDI vs SRS-22 Function: −0.760) in patients with spinal deformity .The literature comparing untreated AIS with normal controls was recently reviewed and statistically analysed . Twenty-A few studies on the conservative management of adolescents with idiopathic scoliosis have included control groups not braced. In the series reported by Pham et al. , a subgrp < 0.0001). The authors used the parents’ forms for the Child Health Questionnaire (CHQ) and the American Academy of Orthopaedic Surgeons Pediatric Outcomes Data Collection Instrument (PODCI). National normative values were available for the CHQ but not for the second instrument. No significant differences between the two groups of patients (observed vs braced) were reported for any of the pain dimensions of the two questionnaires. Moreover, when compared with the scores of healthy children, those with AIS showed similar scores on the bodily pain domain of the CHQ [Another study compared 78 patients with AIS being braced with 136 patients being observed. The two groups were very similar except for the magnitude of the curves (24.6° for the observed subjects and 34.5° for those being braced,  the CHQ .The main references quoted in this section are summarized in Table Back pain in adolescents is quite common, especially in girls. There is no doubt that some AIS patients are back pain sufferers; however, pain does not seem to be a major problem for the vast majority of adolescents with an idiopathic form of this type of deformity. Some elements from the literature suggest that the link between pain and scoliosis is not strongly linked with a biomechanical problem. In most studies, pain has not shown a strong correlation with the Cobb angle, untreated cases fare reasonably well from the perspective of back pain, there is a much greater difference between genders in the incidence of scoliosis compared with the epidemiological data on back pain, and patients’ self-perception of their image correlates with pain. All these findings argue against a major aetiological role of the idiopathic scoliotic deformity of adolescents on back pain. However, the impact of pain in adults’ scoliosis is entirely different , 72 and


Renal colic can be managed by preventing the contraction movements of ureter muscles. By reducing acetylcholine in the nerve terminals, magnesium sulfate could be effective in this regard. The aim of this study is to investigate the effect of magnesium sulfate on acute renal colic pain relief.The present study was a double-blind clinical trial in which the patients suffering from acute renal colic were randomly divided into 2 groups of who either received standard protocol  or standard protocol plus 15 mg/Kg of intravenous magnesium sulfate 50%/100 ml normal saline/15 minutes. Severity of patients’ pain was measured by visual analogue scale (VAS) at baseline, and 30 and 60 minutes after infusion. The collected data were analyzed using STATA statistical software. 100 cases were randomly allocated to intervention or control group. The two groups were similar in baseline pain score and demographic characteristics. At 30 and 60 minutes, mean pain score was less in the intervention group compared to the control group. Moreover, the difference between the two groups was statistically significant regarding the additional amount of morphine, suggesting that the intervention group needed less additional morphine than the control group.The results of this study showed that Magnesium sulfate can be used as an adjunct drug in treatment of patients suffering from renal colic. It not only alleviates the pain in the patients, but also diminishes the need for pain medications.  Urinary tract stone is a common urological disease, which is often symptomized through twinges localized to the sides or a radicular pain towards groins and genitalia, which is referred to as renal colic . Due to Study design and settingThis randomized double-blind clinical trial was designed to investigate the effect of intravenous magnesium sulfate in pain relief of patients presenting to emergency department (ED) following renal colic. Ethical Consideration Before being included in the study, all the patients were provided with proper explanation about the study and they signed the informed consent for being included. They were free to decline to participate and to withdraw from the study. All the research group members were required to comply with all the provisions of the Declaration of Helsinki and Arak University of Medical Sciences research ethics. In addition, this project has been approved by Arak University of Medical Sciences Ethics Committee (Code: Arakmu.ac.1394.44). This study is registered on Iranian registry of clinical trials with the registration number: IRCT2016020223552N6.ParticipantsPatients suffering from acute renal colic admitted to the ED of Vali-Asr Hospital, Arak, Iran, comprised the target population of this study. The cases were enrolled using convenient sampling, considering some inclusion and exclusion criteria. Inclusion criteria were as follows: being clinically diagnosed as renal colic, being between 18 to 55 years old, and having a pain severity > 5 based on visual analogue scale (VAS) .Exclusion criteria were as follows: a history of seizure; any heart, liver, kidney or metabolic disease; fever , systolic blood pressure less than 90 mm Hg, pregnancy, acute abdomen, paregoric drug consumption 3 hours before presenting to ED, history of addiction or drug allergy, and having taken calcium channel blockers.Renal colic was clinically defined through diagnosis of such practical benchmarks as twinges localized to the sides or radicular pain towards groins, lower abdomen and testicles with probable associated symptoms like nausea, vomiting, sweating, pallor, dysuria, frequent urination, urgency of urination, and blood in the urine. Suspected cases of acute coronary syndrome were ruled out with electrocardiography.Randomizationand Sequence generationPatients were randomly allocated to two groups using a balanced block randomization technique. To do that, they were divided into blocks of 6. Allocation of the subjects into two groups was done with the help of an online application called “Sealed Envelope” . In thisImplementationRandom allocation sequence was performed by our methodologist colleague through Sealed Envelope website. Eligibility assessment of the patients and their allocation was conducted by the emergency resident under the supervision of the main person responsible for the project.BlindingIn this study, the patients and the one who was responsible for measuring the desired outcomes in different groups were both blind to group allocation of patients. InterventionAn emergency medicine specialist randomly divided the patients into 2 groups. In the first group, the patients were treated with the standard protocol of 0.1 mg/Kg of intravenous morphine sulfate, 30 mg of intravenous ketorolac, and 100 ml intravenous normal saline, as placebo, within 15 minutes. In the second group, along with the standard protocol, 15 mg/Kg of intravenous magnesium sulfate 50% in 100 ml normal saline was additionally infused within 15 minutes .OutcomesSeverity of patients’ pain was measured by VAS  at baselClinically significant pain relief was considered as ≥ 3 score decrease of pain severity on VAS. Statistical analysis Based on the mean pain scores, in magnesium sulfate and normal saline groups  , alpha et-test and repeated measure ANOVA. P value less than 0.05 was set as the significance level. The study analysis approach was that of intention to treat. Data were analyzed using STATA 13 software through Baseline characteristics100 patients (50 patients per group) were randomly allocated to two treatment groups. Patients’ flowchart is shown in OutcomesIn No significant differences in terms of nausea, vomiting, itching and drowsiness were, observed between the two groups. Likewise, no cases of dizziness were reported in the groups.The average additional morphine received, in the control group was significantly higher than that of the magnesium sulfate group .The findings of present study suggest that adding magnesium sulfate to standard protocol of renal colic management could be effective in reducing the patients’ pain and need for additional dose of morphine sulfate without disturbing hemodynamic measures. However, the amounts of these effects are not clinically significant.Magnesium plays key roles in several physiological processes. It has been stated to potentiate lidocaine , induce Examining the impact of low-dose magnesium sulfate infusions on pain after laparoscopic cholecystectomy surgery, Kocman et al.  found thIn 2006, Safdar et al.  study shRezae et al. (2014) examined the effect of magnesium sulfate infusion on pain relief after cesarean section and declared that infusion of 50 mg/kg magnesium sulfate reduces the pain and diminishes the need for other pain medications as well . Studying the bronchodilating effect of intravenous magnesium sulfate in bronchial asthma, Okayama et al.  also fouIn our study, adding magnesium sulfate to the standard treatment of patients with renal colic reduced the severity of pain and decreased the need for additional morphine. Considering that no side effects have been reported for using magnesium sulfate, as well as its easy application, this drug can be used as an adjunct drug in treatment of patients suffering from renal colic. Simultaneous use of magnesium sulfate with other drugs can also reduce their dosage and possible side effects. LimitationThe main limitation of this study was sample size. Due to small sample size and maybe low statistical power, it is recommended that further studies with larger sample sizes be conducted to examine any possible side effects for this drug and to confirm or reject the findings of this study.The results of this study indicated that magnesium sulfate can be used as an adjunct drug in treatment of patients suffering from renal colic. It can reduce the pain and diminish the need for additional doses of morphine sulfate without disturbing hemodynamic measures. However, the amounts of these effects are not clinically significant.


A 32-year-old female with a history of cholecystectomy three years prior, presented to the emergency department with epigastric pain. Liver function tests (LFTs) were abnormal , however ultrasound (US) imaging was negative for gallbladder pathology and the patient was discharged home with normal vital signs and instructed to follow up in two days if symptoms persisted. At her follow up visit, her LFTs worsened  and the patient underwent a magnetic resonance cholangiopancreatography (MRCP) which showed a dilated common bile duct (CBD) with filling defect suspicious of stone . The patApproximately 5% of patients who have undergone cholecystectomy continue to have symptoms of abdominal pain, vomiting, dyspepsia, loose stool, and are thought to suffer from postcholecystectomy syndrome (PCS).1CBD stones are a serious complication after cholecystectomy, therefore the diagnosis of PCS must always be considered in patients status post cholecystectomy with upper abdominal pain.What do we already know about this clinical entity?Magnetic resonance cholangiopancreatography (MRCP) identifies retained stones in patients with prior gallbladder surgery, however MRCP is not a tool readily available to emergency physicians.What is the major impact of the image(s)?Given the wealth of information provided, perhaps MRCP imaging can be incorporated as part of a routine postcholecystectomy syndrome (PCS) workup and help to limit unnecessary hospital admissions.How might this improve emergency medicine practice?MRCP imaging can help to improve diagnostic capabilities for patients suffering from PCS presenting to the emergency department.


We aimed to compare the effects of intraoperative lidocaine and magnesium on postoperative functional recovery and chronic pain after mastectomy due to breast cancer. Systemic lidocaine and magnesium reduce pain hypersensitivity to surgical stimuli; however, their effects after mastectomy have not been evaluated clearly.In this prospective, double-blind, clinical trial, 126 female patients undergoing mastectomy were randomly assigned to lidocaine (L), magnesium (M), and control (C) groups. Lidocaine and magnesium were administered at 2 mg/kg and 20 mg/kg for 15 minutes immediately after induction, followed by infusions of 2 mg/kg/h and 20 mg/kg/h, respectively. The control group received the same volume of saline. Patient characteristics, perioperative parameters, and postoperative recovery profiles, including the Quality of Recovery 40 (QoR-40) survey, pain scales, length of hospital stay, and the short-form McGill pain questionnaire (SF-MPQ) at postoperative 1 month and 3 months were evaluated.P = 0.003). Moreover, in sub-scores of the QoR-40 dimensions, emotional state and pain scores were significantly higher in group L than those in groups M and C . At postoperative 3 months, SF-MPQ and SF-MPQ-sensitive scores were significantly lower in group L than in group C .The global QoR-40 scores on postoperative day 1 were significantly higher in group L than in group C (Intraoperative infusion of lidocaine improved the quality of recovery and attenuated the intensity of chronic pain in patients undergoing breast cancer surgery. At most, 60% of patients who undergo mastectomy for breast cancer experience chronic pain ,2, whichs block provide better functional recovery or superior pain control after breast cancer surgery ), and nominal factors are expressed as n . We performed a one-way analysis of variance (ANOVA) for intergroup comparison of continuous variables. The hypothesis of a normal distribution was confirmed using the Kolmogorov–Smirnov test. Nominal variables, such as the incidence of chronic postoperative surgical pain, are reported as numbers and percentages; these variables were compared among groups by using the Chi-squared test and Fisher’s exact test, as appropriate. Accordingly, the primary outcome  was assessed using an ANOVA, and the secondary outcome (postoperative pain profiles) was analyzed using ANOVA and chi-square tests. In cases of statistical significance, P = 0.003), and the total amount of remifentanil consumption was significantly lower in groups L and M than in group C (P < 0.001).The CONSORT flowchart of present study is shown in P = 0.003). In sub-scores of the QoR-40 dimensions, the emotional state and pain scores were significantly higher in group L than in group C .The global QoR-40 scores and the sub-scores of QoR-40 dimensions of the preoperative and POD 1 are presented in P < 0.001 in both groups at PACU, and P = 0.001 and 0.046 at postoperative 6-24 hours, respectively). The pain NRS at postoperative 1-6 hours was significantly lower in group L than in group C (P = 0.017). However, there were no significant differences in the postoperative intravenous calculated morphine equivalent dose, incidence of PONV, antiemetic consumption at the PACU and during POD 1, and in the length of the hospital stay .Outcomes associated with postoperative acute pain are presented in tal stay . Table 5The present study shows that intraoperative systemic lidocaine improves postoperative quality of recovery, as measured by the QoR-40 survey. Additionally, lidocaine reduced the intensity of chronic pain, and intraoperative opioids requirement in patients undergoing mastectomy for breast cancer. However, intraoperative systemic magnesium was only effective in reducing intraoperative opioid consumption and pain score in the early postoperative period. To our knowledge, the present study is the first to report the effects of systemic lidocaine and magnesium on quality of recovery using the QoR-40 survey and chronic pain with SF-MPQ after breast cancer surgery.Adequate functional recovery soon after surgery is very important. Traditionally, several parameters including pain, PONV, length of stay in the recovery room, and length of hospital stay are used to estimate postoperative recovery status . RecentlDe Oliveira et al. showed that systemic magnesium enhanced QoR-40 scores at the 24-hour postoperative period in patients undergoing outpatient segmental mastectomy [Our study showed that both lidocaine and magnesium reduced opioid consumption during surgery and pain intensity during the acute postoperative period. One study, which compared the effects of systemic lidocaine and magnesium on postoperative recovery with traditional parameters for patients undergoing laparoscopic cholecystectomy, reported similar results as ours . Howeverstectomy . ConsideChronic or persistent postsurgical pain is defined as pain that develops after a surgical procedure that lasts at least 2 months, and where other causes  have been excluded . It has N-methyl-D-aspartate (NMDA) receptors is a common analgesic mechanism of lidocaine [odocaine and magnesium showed different effects on postoperative recovery and chronic pain intensity. Even if we consider that systemic magnesium decreased postoperative acute pain scores and ended to enhance the global QoR-40 on POD 1 and KSF-MPQ at the 3-month postoperative period, only systemic lidocaine had widely favorable effects on early postoperative recovery and chronic pain control. The reason for this discrepancy might be that lidocaine acts via multiple mechanisms for producing analgesia. For example, along with inhibiting NMDA receptors, systemic lidocaine is known to block sodium channels in neurones [Inhibition of idocaine  and magnidocaine . Howeverneurones , inhibitneurones , and mitneurones .Several limitations of this study should be addressed. First, we did not measure serum lidocaine concentrations. If we had conducted this measurement, the effective dose of lidocaine could have been determined, and the adverse effects of lidocaine could have been monitored more specifically. Nonetheless, the safety of a low-dose lidocaine infusion has been demonstrated in other studies ,34. SecoIn conclusion, intraoperative systemic lidocaine enhanced postoperative quality of recovery after mastectomy, and improved chronic pain control. While the magnitude of improvement was statistically significant, it is probably less clinically relevant. Therefore, based on this study, we suggest that intraoperative lidocaine administration could be a safe and useful method to manage overall postoperative recovery for patients undergoing mastectomy due to breast cancer.S1 File(DOC)Click here for additional data file.S2 File(DOC)Click here for additional data file.S3 File(DOCX)Click here for additional data file.S4 File(XLSX)Click here for additional data file.


Propensity scores are typically applied in retrospective cohort studies. We describe the feasibility of matching on a propensity score derived from a retrospective cohort and subsequently applied in a prospective cohort study of patients with chronic musculoskeletal pain before the start of acupuncture or usual care treatment and enrollment in a comparative effectiveness study that required patient reported pain outcomes.We assembled a retrospective cohort study using data from 2010 to develop a propensity score for acupuncture versus usual care based on electronic healthcare record and administrative data  from an integrated health plan, Kaiser Permanente Northwest. The propensity score’s probabilities allowed us to match acupuncture-referred and non-referred patients prospectively in 2013-14 after a routine outpatient visit for pain. Among the matched patients, we collected patient-reported pain before treatment and during follow-up to assess the comparative effectiveness of acupuncture. We assessed balance in patient characteristics with the post-matching c-statistic and standardized differences.Based on the propensity score and other characteristics , we were able to match all 173 acupuncture-referred patients to 350 non-referred  patients. We observed a residual imbalance (based on the standardized differences) for some characteristics that contributed to the score; for example, age, -0.283, and the Charlson comorbidity score, -0.264, had the largest standardized differences. The overall balance of the propensity score appeared more favorable according to the post-matching c-statistic, 0.503.The propensity score matching was feasible statistically and logistically and allowed approximate balance on patient characteristics, some of which will require adjustment in the comparative effectiveness regression model. By transporting propensity scores to new patients, healthcare systems with electronic health records can conduct comparative effectiveness cohort studies that require prospective data collection, such as patient-reported outcomes, while approximately balancing numerous patient characteristics that might confound the benefit of an intervention. The approach offers a new study design option. Propensity scores are an increasingly popular method of controlling potential confounding in observational studies that compare the effectiveness of healthcare interventions , 2. PropTo date, propensity score methods have not been used to recruit and match subjects on an ongoing basis in prospective cohort studies that require the collection of patient-reported outcomes (PROs). PROs may be required at baseline  or may be required as an outcome. Examples of such PRO data include self-reported measures of depression or pain. While the systematic collection of PROs in the EHR remains uncommon in routine practice settings, collection of PROs is increasing .This paper details a novel use of a propensity score to permit ongoing matching in a prospective cohort study comparing the effectiveness of acupuncture versus usual care to treat pain in patients with chronic musculoskeletal pain (CMP). A propensity score offered a more efficient approach statistically and logistically for enrollment in the prospective cohort study than alternative study designs. We sought to match on patients’ pre-treatment Brief Pain Inventory score because it served as an outcome for evaluating the comparative effectiveness of acupuncture. The Brief Pain Inventory could only be collected by interviewing patients; it was not collected systematically in routine practice. Had we matched on Brief Pain Inventory score and enrolled patients in the cohort for additional prospective data collection of patient reported outcomes, we could have developed a propensity score after enrollment finished to adjust for additional patient characteristics that might confound the acupuncture effect. Some patients on whom we would have collected patient-reported outcomes would have been excluded from the analysis because of a lack of overlap in their propensity scores , which would have resulted in a loss statistically (worse precision) and a loss logistically (wasted research staff effort). Given a pre-determined level of research funding, we sought to invest in prospective data collection for those patients who would contribute to the estimate of comparative effectiveness. Using recent historical EHR and other administrative healthcare data, we developed a propensity score to predict the probability of referral and initiation of acupuncture in patients with CMP. We matched patients by deciles of propensity as we enrolled them in the prospective cohort study to reduce imbalance in the final comparison groups. Our paper describes the feasibility of our approach and assesses the degree of balance in baseline characteristics that we achieved.Our prospective cohort study, the RELIEF study, has been described elsewhere . AlthougWe identified adult members at KPNW, an integrated delivery system with approximately 480,000 members, who had a diagnosis for chronic pain documented in the EHR on at least three pain-related outpatient visits over a six to 18-month period. The pain had to be chronic in that it occurred over at least six months. We allowed up to 18 months for patients to meet the criteria for three pain-related visits. One of the three pain-related visits had to include a diagnosis of chronic musculoskeletal pain. We excluded patients with cancer, dementia, psychoses (or transient psychotic episodes), and those in hospice.From that source population, we identified patients with subsequent referral and documented use of acupuncture during 2010. We also identified a comparison group of patients who met the same eligibility criteria but who had no evidence of subsequent referral and use of acupuncture after their most recent visit for chronic pain in 2010. We then excluded patients with a recent prior referral for acupuncture or use of acupuncture (within the past six months) because a valid propensity score requires incident users . PatientWe then developed a propensity score model to predict initiation of acupuncture using logistic regression . Potentia priori in consultation with physicians instead of using statistical significance or other data-dependent variable reduction strategies. Our a priori strategy reduced optimism in the propensity score coefficients that would have reduced its effectiveness in future populations  . We used – arcsinWe also calculated c-statistics for our propensity score models. C-statistics are traditionally used to measure the discriminatory power of a predictive model, and for logistic regression are equivalent to the area under the receiver operating characteristic curve. Thus, a c-statistic of 1.0 represents perfect discrimination, while a c-statistics of 0.5 represents no discrimination between those who initiated acupuncture and those who did not initiate. The c-statistic played no role in our selection of pre-treatment characteristics  and should not be interpreted as a measure of how well the propensity score may control confounding . Our priWe used our study-specific chronic pain registry (current KPNW patients who met our EHR study definition of likely CMP) to assemble a cohort of 60,516 eligible patients in 2010. Of these, 952 (1.6%) started acupuncture during 2010. Table The majority of characteristics included in the propensity score model exhibited differences between the two patient cohorts. Patients who started acupuncture, for example, were more likely to have used pain medication . Likewise, most of the pain-related characteristics were more common among those who started acupuncture . A more general measure of comorbidity, the Charlson score (Deyo’s adaptation), showed a negligible imbalance with a standardized difference close to zero. The corresponding c-statistic for the variables in the propensity score model was 0.739, which reflects the broad imbalance between the cohorts in these variables and the propensity score model’s ability to discriminate between the cohorts. After adjusting for propensity score decile using 10 indicator variables, however, the balance of the characteristics in the propensity score model improved. All of the standardized differences were close to zero and no values were greater than 0.05 or less than -0.05.Many of the characteristics that were not included in the propensity score model were also imbalanced between patients who started acupuncture and those who did not Table . Back orThe propensity score model developed with data from 2010 validated adequately in a distinct cohort of patients from 2011 . The propensity score’s agreement between predicted and observed probabilities of acupuncture initiation was also adequate .Patient scored < 4 on the Brief Pain Inventory’s pain bothersome scale (ranged from 0 to 10).Patient’s pain was not chronic.Patient had a recent history (past six months) of undocumented acupuncture performed outside of KPNW.Patient had already started acupuncture at KPNW and we could not obtain pre-treatment measures.Patient was pregnant.Patient intended to move outside of the KPNW coverage area and would be lost to follow-up.We identified 1154 patients referred for acupuncture from the study-specific chronic pain registry and invited them to be screened for the prospective cohort study . A total of 1013 control cohort patients agreed to take the screener’s survey and 257 patients were ineligible according to the criteria.We screened 414 (36%) patients and determined that 252 patients were eligible for the acupuncture-referred cohort. As those 252 patients became eligible we calculated their propensity scores. The matching of control patients occurred in two steps. Once we identified an eligible patient referred for acupuncture, we selected a pool of possible control patients whose propensity score probability was in the same decile as the acupuncture-referred patient. Control cohort patients were not referred for acupuncture but had a recent pain-related visit. At that stage, the possible controls were only matched on the propensity score decile and control patients were invited to be screened according to the criteria listed above. In most instances, we identified more possible controls than required to match two control patients, so the majority were closed-out and never screened  The patient could not be matched on the patient-reported Brief Pain Inventory score (which was only collected during screening) and sex; (2) the patient was no longer required as a control because we had already identified two control patients for the patient referred for acupuncture; (3) the patient experienced technical problems with the online enrollment process, which occurred more commonly in the early study recruitment. A few patients refused to participate in the prospective cohort study. After all of those considerations itemized in the Figure, 350 control cohort patients consented to the prospective cohort study. Control patients were frequency-matched to 173 acupuncture-referred patients.Table We also evaluated characteristics that may predict pain and confound the estimate of comparative effectiveness, but were not in the propensity score. The least balanced characteristics ranked by standardized difference were: fibromyalgia or other myofascial pain, 0.327; headaches, 0.252; neuropathy, -0.240; back or neck pain, 0.223; white race, -0.176; two types of non-chronic pain, 0.132; carpal tunnel syndrome, -0.116; antidepressant medication use, 0.110, and depression, -0.109.We implemented a novel application of a propensity score in which we initially developed a propensity score in one cohort of patients and then used that propensity score to match patients on an ongoing basis in a distinct prospective cohort study to evaluate the comparative effectiveness of acupuncture. Our development cohort demonstrated that providers refer—and patients initiate—acupuncture preferentially according to measured patient characteristics, including markers of chronic pain severity . Our prospective cohort demonstrated that propensity score matching provided approximate balance across the variables used to fit the propensity score model and additional variables not included as part of the propensity score model. However, some of the patient characteristics that were imbalanced  will require adjustment in the comparative effectiveness regression model to reduce residual confounding.Our prospective cohort study compared patients with chronic musculoskeletal pain who were referred for acupuncture with those who were not referred for acupuncture. Some characteristics appeared imbalanced in the prospective cohort study based on their standardized differences, which were as large as -0.283 . In contrast, the overall balance was adequate based on the post-matching c-statistic (0.503), which exhibited little room for improvement relative to a score of 0.5 that would be expected with randomly-generated treatment assignments . AlthougThis study adds important data to the growing body of literature describing interventions that used propensity scores , 15. A rHad it been feasible to compare the effectiveness of acupuncture (versus no acupuncture) based on an outcome that did not require collecting patient-reported outcomes (PROs), we could have conducted the cohort study on a broader population of treated and untreated patients without the need for ongoing matching, and then conducted traditional propensity score adjustment after the fact. That’s the typical scenario in retrospective cohort studies of comparative effectiveness or safety of treatments for pain: the outcome is collected during routine practice and documented at no expense to the investigators , 19.Our prospective study required us to collect PROs before acupuncture treatment and repeatedly during the six-month follow-up. PROs require patients’ informed consent and are expensive to collect. As a result, we limited collection to those patients who met the eligibility criteria . While we enrolled all patients referred for acupuncture, we limited data collection of non-referred patients to those who were matched on decile of the propensity score. Using this design meant that we had to calculate each patient’s propensity score before enrollment in the prospective cohort, which was only possible using a propensity score developed using data from an historical cohort of similar patients; we hoped the historical propensity score would work well in our prospective cohort. The temporal validation of the propensity score and the approximate balance in the prospective cohort, as reported in the Results, support the effectiveness of this approach.and initiation of acupuncture . To serve the needs the prospective study, we had to enroll patients solely on the basis of referral for acupuncture  in order to collect the needed baseline (pre-treatment) measurements. Because we recruited patients for a prospective study that required their consent to participate, our prospective cohort was subject to a potential selection bias that did not exist for the historical cohort used to develop the propensity score. Finally, we selected the first two controls patients who met criteria and agreed to participate to ensure that we could recruit an adequate number of non-referred, matched controls in a timely manner. As such, the non-referred patients who replied more quickly may differ in subtle ways from the larger pool of potential controls. This could introduce selection bias between those referred and not referred for acupuncture. While a combination of these factors could limit the effectiveness of the propensity score matching, our final referred and non-referred cohorts were approximately balanced.The matching worked despite several threats to its validity. First, the propensity score was developed to predict referral Using propensity scores in prospective cohort studies is statistically and logistically feasible for health plans with electronic health records and integrated data. Their use, however, requires significant resources, including substantial effort during the period of recruitment, including ongoing analytic support. For example, information from a number of different data sources  had to be brought together in real time to identify potential comparison participants and enroll them in the study, which required a complex set of data transfers. The identification process could fail at various points. Accordingly, time devoted to building and maintaining this system, along with computational needs, were substantially greater than anticipated. Further, when system glitches occurred , recruitment processes needed to be suspended until the problem was adjudicated and systems were realigned. These challenges limited overall study recruitment.While using this method was labor-intensive, the application of this new use of propensity score methodology may become increasingly efficient with more experience . For exaWhenever investigators need to collect data prospectively in a cohort study evaluating comparative effectiveness, this approach may save time and money as well as reduce participant burden by collecting data only from patients who will contribute to the analysis. Prospective data collection is often required for behavioral health interventions, which depend on patient-reported covariates and outcomes, such as depression or pain. Prospective data collection is also required for many clinical studies, such as detailed clinical evaluations , expensive laboratory tests, and diagnostic imaging. In these instances, prospective data collection may improve control of confounding as well as the assessment of treatment effect heterogeneity . Our stu


In addition to tumour treatment, the management of symptoms such as pain is an important component of cancer care. Pain management is a complex field and prior studies have highlighted many different clinical care responses to a cancer patient presenting with severe pain. We explored follow-up and how pain screening scores changed over time, among a cohort of cancer outpatients, and how follow-up was scheduled after the initial visit.The care provided to 96 patients seen at the London Regional Cancer Program was reviewed for the 12-week period following presentation with severe pain >7/10. Follow-up ESAS (Edmonton Symptom Assessment System) scores, visits, and compliance were documented.Follow-up ESAS data was available for 41/96 patients. Mean ESAS pain decreased from 8.4/10 to 3.6/10 among those patients with follow-up; however, for 55/96 patients, no follow-up ESAS score was available .Despite a very high proportion of documented active pain management plans in the case of cancer patients presenting with severe pain, very little follow-up directed specifically at pain management was performed. Cancer treatment appears to be the primary determinant of oncology follow-up timing at our centre. Pain is one of the most prevalent symptoms in patients with metastatic cancer and has wide-ranging deleterious effects on activity, mood, and sleep, to name a few . QualityAddressing some of the concerns surrounding pain management has been difficult, and the various components of the pain management process need to be defined and improved -9. AssesIn a previous study at the LRCP by Sanatani et al., a high proportion (83%) of patients who reported severe pain (ESAS >7), received an active intervention targeted at managing that pain . FurtherInformed consent was obtained from patients, and IRB approval was provided by Western University Health Sciences Research Ethics Board .The purpose of the present study was to determine the mean changes in ESAS pain score from baseline, occurring at follow-up visits after the implementation of various pain management regimens in patients presenting with severe pain 7-10/10). The follow-up pain scores were recorded for the visits as listed in Table 0/10. TheA retrospective chart review was done (both electronic and paper contents) on the patients previously selected and reported on by Sanatani et al . The patNinety-six charts were found eligible for this follow-up study and were reviewed (both electronic record and paper chart including nursing documentation). Baseline characteristics are indicated in Table The changes in ESAS pain scores for those patient visits captured within the 12-week follow-up window are indicated in Table Associations between patient characteristics and the change in ESAS pain score from baseline to longest follow-up were examined. No significant predictive factors were found.In this follow-up study, 96 patient charts were reviewed to assess the changes in pain scores reported by cancer patients after a baseline visit where they had indicated their pain was severe (>7/10). As documented in our earlier study , the sevIn fact, the majority of patients’ first follow-up visits were not captured in this study, as they fell outside the three-month window after the baseline visit was reviewed. Follow-up visit scheduling did not appear to be short-term, as 37 out of 96 patients received their next visit three months or later after baseline. At our centre, at the time of this study, follow-up visit timing was entirely at the discretion of the oncologist, and an electronic follow-up booking order, set with prepopulated, recommended follow-up timeframes, was not in use yet (as it is now). Therefore, the timing of the booked follow-up visit entirely reflects the conscious clinical decision of the oncologist. We therefore conclude that despite the initial attention given to the severe pain, in-clinic follow-up was often not arranged primarily to reassess pain levels in the short-term but was perhaps linked more to the expected progression of the underlying cancer.The limiting factor in generalization of the results of this study is the relatively small number of patients actually seen in follow-up. It is unknown what occurred in many patients with respect to their pain management as a large proportion received no follow-up within three months after severe pain was documented on the ESAS. Nevertheless, for those patients for which follow-up data is available, pain documented by the ESAS decreased from baseline at each subsequent interval over the 12-week period. No associations were discovered between other ESAS scores and a change in pain level over 12 weeks. Similarly, Hwang et al.  describePrevious studies have shown similar findings in that pain ratings from admission to follow-up were decreased, and this reduction was not associated with treatment . DeardofIn this study of oncology follow-up after an initial patient presentation with severe pain, we found that only a minority of patients had oncology follow-up booked within three months. This leads to the conclusion that despite pain having been addressed at the initial visit, this assessment did not necessarily lead to follow-up in a timely manner to specifically reassess the pain. In a subset of the 96 cancer patients initially reporting severe pain, reduction in pain was observed over time, independent of several variables including type of pain and type of treatment. However, this finding was limited by small numbers available for follow-up. This study illustrates that pain level reassessment itself did not appear to be the main determinant of booking follow-up. Given the physical constraints of a typical cancer centre, perhaps alternative forms of support and follow-up, other than a clinic visit, could be considered when assessing a patient with severe pain. This could take the form of timed telephone calls, mail survey follow-up, or more precise communication to the primary healthcare providers with regard to pain management follow-up steps.


Recent studies have shown the positive effect of magnesium sulphate (MgSO4) on pain reduction and postoperative analgesic requirements in patients undergoing surgery. We assessed the effect of MgSO4 on intra-operative and postoperative analgesic requirements in patients undergoing lower abdominal gynecological laparotomy.This randomized clinical trial was conducted on 30 female patients at Rasool-e-Akram  hospital in Tehran from August 2012 to March 2013. The patients who were candidates for gynecologic surgeries (hysterectomy and/or myomectomy) were randomized into study (n=15) and control (n=15) groups. Same anesthetic technique was used in all patients. Besides induction of the anesthesia in the study group, we administered MgSO4 50 mg/kg/hr intravenously (IV) for analgesic purposes as a bolus dose and then 8 mg/kg IV as maintenance dose. Control group received the same anesthetic agents and the same amount of isotonic saline instead of MgSO4. Analgesic consumption was measured in both groups postoperatively within 24 hours. The visual analog scale (VAS) was used for the evaluation of postoperative pain in both groups.There was a decrease in analgesic consumption and pain in the group receiving MgSO4, in comparison to control group. Pain severity assessment, 24 hours post operatively showed similar results in both groups. There was a statistically significant difference in prescribed dose of pethidine between study and control groups (p=<0.0001).Intra-operative MgSO4 is effective in postoperative pain control following lower abdominal laparotomy. Further studies with larger sample sizes and longer follow-up should be performed to obtain more information about safety and to determine whether doses of MgSO4 can provide postoperative analgesic benefits. Appropriate analgesia can reduce morbidity and complications in surgical patients by blunting autonomic, somatic and endocrine reflexes. Abdominal hysterectomy and myomectomy are the most common major gynecological surgeries that are performed using laparotomy method and post-operative pain control is one of the main problems in patients undergoing these operations.Postoperative pain control has always been an arguable issue amongst surgeons. The incidence of postoperative pain described by patients differs in various studies. In one of these studies, approximately 75% of patients undergoing surgery suffered from acute postoperative pain,5. Although its mechanism of action is not clearly understood, interference in N-methyl-D-Aspartate (NMDA) receptor regulations is assumed to play an important role.Magnesium is an intracellular cation that contributes to adjustment of enzyme reactions and adjustment of ionic channels. It is also being used for anesthetic purposes due to its blocking effect on calcium channels,8,9,10.Several studies have evaluated the role of magnesium sulfate (MgSO4) as an agent for pain control and reduction of analgesia requirement intra-and post-operatively. In some of these studies, researchers concluded that MgSO4 may reduce the need for opioid analgesic agents. Finding a safe and cost-effective method for reducing pain has always been a debate and issue in surgical fields. The aim of this study was to evaluate the effect of MgSO4 on intra-operative and postoperative analgesic requirements in gynecologic surgeries.Narcotics such as pethidine are the most widely used and cost-effective agents in postoperative pain control. However, side effects associated with their usage is a concernThis double-blind study was carried out on 30 women aged 36 to 56 years old who fulfilled the American Society of Anesthesiology (ASA) class I-II criteria for elective lower abdominal laparotomy (hysterectomy and myomectomy) in a tertiary academic hospital. This study was approved by the Ethics Committee of Iran University of Medical Sciences. Exclusion criteria included allergy to MgSO4, renal or hepatic or cardiovascular dysfunction, neurological disorders, atrioventricular conduction disturbance, opioid or analgesic abuse, and long-term treatment with calcium channel blockers or magnesium. Prior to induction, monitoring was started with electrocardiogram (ECG), pulse oximetry and noninvasive blood pressure measurement.In the operating room, isotonic saline infusion  was started and continued during the operation for all patients..Technique of general anesthesia was similar in all patients: midazolam (0.2 mg/kg) as premedication, propofol (2 mg/kg), fentanyl (2 µg/kg) as induction agents, and atracorium besylate (0.5 mg/kg) for tracheal intubation. In the maintenance phase, propofol (100-150 mg/kg/min) and remifentanyl (0.4 µg/kg/min) were used. Fentanyl (1 mg/kg) was administered before the end of operation, and at the end of surgery, neostigmine (0.04 mg/kg) and atropine (0.02 mg/kg) were given in order to reverse the actionA total of 30 patients were randomized to receive 50 mg/kg of MgSO4 in 100 ml of isotonic saline over 10 min immediately before the induction of anesthesia and then 8 mg/kg/hr by continuous IV infusion until the end of the operation (study group) or to receive the same volume of an isotonic saline solution (control group). The patients and anesthesiologist were blinded. The study data were recorded by an observer who was blinded to both groups. MgSO4 and anesthetic agent infusions were discontinued at the time of skin closing. After the end of surgery, the visual analog scale (VAS) from 0 to 10 (with 0 representing no pain and 10 representing the worst imaginable pain) was used for postoperative pain evaluation several times .If a patient complained of pain or VAS was higher than 4, then 30 mg of pethidine was injected and, if needed, the same dose was repeated q 3 hours till the patient was free of pain. The total dose and number of doses injected were recorded. Postoperative nausea, vomiting, respiratory rate, blood pressure, heart rate, deep tendon reflex, and level of consciousness were recorded throughout the study period.Data were registered in checklists including demographic characteristics, patient’s complaints, VAS score, and amount of pethidine dosage. Numerical variables were reported as mean ± standard deviation (SD). We used an independent-t-test and chi-square test to compare quantitative and qualitative variables, respectively. A p value of ≤0.05 was considered statistically significant. All analyses were performed using SPSS for Windows .The mean age of patients was 48.85±4.8 years (range: 36-56) . The patIncidence of nausea or vomiting and cause of surgery  were similar in both groups .In this randomized clinical trial, the effect of MgSO4 on intra-and postoperative analgesic requirements in gynecologic surgeries was assessed. We have shown in this study that MgSO4 infusion during operation reduced postoperative pain .In this study, we prescribed 50 mg/kg MgSO4 as a bolus dose and 8 mg/kg/hr as a maintenance dose. Serum Mg concentrations in study group was higher than in patients in control group after surgery, but there were no complications associated with hypermagnesaemia.Based on our results, opioid consumption and pain severity scores were both significantly lower in the study group at 30 minutes, 2 hours, 4 hours and 12 hours, postoperatively.,14,15.Previous studies have also reported that magnesium administration significantly reduces opioid analgesic drug requirements.Also it has been shown that MgSO4 may reduce anesthetics requirements. In their study, Choi and colleagues demonstrated that the usage of propofol reduced from 167 to 81 mg/kg/min after administering bolus dose of MgSO4 (50 mg/kg) followed by continuous MgSO4 infusion (8 mg/kg/min) in gynecological surgery.Seyhan and colleagues compared the effect of MgSO4 infusion on amount of anesthetic requirements and postoperative pain. Based on the results of their study, infusion of MgSO4 in patients significantly reduced the amount of intra-operative propofol and neuromuscular blocking agent. Postoperative pain and opioid analgesics consumption was also reduced. Ryu J H and colleagues showed that MgSO4 infusion intra-operatively did not reduce propofol requirements.On the other hand, some studies have shown that MgSO4 does not reduce postoperative analgesic requirements. For example, KO et al. showed that cerebrospinal fluid (CSF) concentration of magnesium did not increase after IV administration of MgSO4 and it had no effects on postoperative pain. On the other hand, they reported an inverse relation between cumulative postoperative analgesic consumption and the CSF magnesium concentration. They concluded that CSF magnesium concentration affects postoperative pain, but perioperative IV magnesium administration had no analgesic effects. However, the mechanism of analgesic effect of magnesium is not completely understood, but it has been proposed that MgSO4 can prevent central sensitization after peripheral nociceptive stimulation and suppress hypersensitivity, and this analgesic property is due to its action on NMDA receptors and calcium channels. Previous studies have also proved this finding that one of the main target sites for general anesthesia is release of glutamate by pre-synaptic calcium channels,20,21.Anesthetic effect of magnesium is believed to be due to magnesium and calcium ions competition in pre-synaptic calcium channels. As shown in our study, intra-operative MgSO4 is effective in postoperative pain and it reduces analgesic requirements, therefore, the need to consume NSAIDs postoperatively may be also decreased.Non-steroidal anti-inflammatory drugs (NSAIDs) are used as an analgesic option for postoperative pain, however, many concerns about adverse effects of these drugs, such as gastrointestinal bleeding, acute renal failure and allergic reactions have limited their usageOur study had some limitations which should be noted; we should have determined concentration of magnesium before the operation and not only after operation, thus, we could evaluate the relationship between magnesium concentration and pain severity following the operation. Also the sample size of our study was small and another study with a larger sample size is necessary to be conducted.Intra-operative and continuous infusion of MgSO4 to women who have undergone lower abdominal laparotomy significantly reduced opioid requirements and pain postoperatively. Further studies with larger sample sizes and longer follow-up should be performed to obtain more information about safety and to determine whether doses of MgSO4 can provide postoperative analgesic benefits.