In South Korea, car insurance that includes medical coverage of traditional Korean medicine (TKM) has increased exponentially. Clinical practice guidelines (CPG) for traffic injuries were established in 2016. We aimed to revise and update de novo CPG and distribute the adapted CPG to TKM practitioners and patients. Clinical key questions from previous CPG were identified and updated regarding the grade of recommendation and level of evidence using additional evidence from the literature obtained through a systematic search and the use of the Grading of Recommendations Assessment, Development, and Evaluation methodology. The dissemination and implementation of the updated CPG were conducted at the CPG Center of Korean Medicine. Ultimately, 25 recommendations based on 13 clinical key questions were developed: 2 for diagnosis, 22 for TKM treatments, and 1 for prognosis. After recognition by professional societies and certification by the CPG Center of Korean Medicine, leaflets, card news, and infographics for TKM doctors in South Korea were produced and distributed. These are the only TKM CPG for patients who have experienced traffic injuries. They are expected to contribute to standardized and evidence-based treatment using TKM and similar interventions. Moreover, disseminating the adapted CPG will promote treatment reliability and strengthen insurance coverage. The Global Status Report on Road Safety 2018 launched by the World Health Organization in 2018 indicated that approximately 1.35 million people die yearly because of traffic injuries and 50 million suffer non-fatal injuries [In South Korea, the average number of traffic accidents during the past 5 years was approximately 210,000, thereby increasing the overall auto insurance cost to USD 20 billion annually by 2020 ,4. The nTKM refers to traditional approaches to medicine practiced in South Korea and includes acupuncture, moxibustion, Chuna manual therapy (CMT), pharmacopuncture, cupping, herbal medicine, and physiotherapy . Korean We aimed to present updated previous CPG as well as the contents of the dissemination including standardized and effective TKM treatment. These CPG are the most systematic and standardized TKM CPG developed for traffic injury. Although these CPG are based on South Korea’s medical system, they have value as a reference for CPG development in other countries using similar interventions including acupuncture and moxibustion. Additionally, the development and implementation of CPG reduce unnecessary medical costs and increase the return-to-work rate after traffic injuries, ultimately contributing to improvements in the quality of TKM practice.After de novo development of CPG , the GKoThe development committee was led by professors of Korean medicine rehabilitation who consulted clinical experts in each field and completed the entire process of CQ development, performed a systematic search for evidence, an analysis of the quality of evidence, GoRs, and revisions of the CPG for traffic injuries. A review and advisory committee consisting of external experts in clinical, academic, and methodological studies examined whether the clinical status in South Korea was reflected in the developed CQs and literature evidence to ensure that the LoE and GoR assignment process was correctly performed. After the development of the CQs associated with the previous CPG in 2016, the results of an evaluation performed by external reviewers and additional literature evidence obtained from a systematic search revealed that the previous CQs were vaguely described, thus necessitating reorganization and segmentation. Hence, the existing CQ section focusing on patients and interventions was preserved; however, the section focused on pain was subdivided, and the evidence was updated based on further literature and systematic research findings from February 2020 to April 2020. Additional surveys, qualitative research, and an economic evaluation have been conducted to obtain sufficient evidence during the CPG development phase ,11,12. TThe LoEs and GoRs of the guidelines were evaluated following the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach developed by Cochrane’s GRADE Working Group . Each idThe revision that incorporated the external reviewers’ feedback was made after the external review of the draft CPG for traffic injuries by the GKoM in October 2020. An external evaluation was conducted by 11 members of the GKoM committee and the external monitoring committee, including methodology and CPG development experts, to ensure that the CPG modification plan was complete and followed the aforementioned process.The CPG for traffic injuries were approved by six related societies: the Society of Korean Medicine Rehabilitation, the Korean Acupuncture and Moxibustion Medicine Society, the Korean Pharmacopuncture Institute, the Korean Society of Chuna Manual Medicine for Spine and Nerves, the Korean Society of Oriental Neuropsychiatry, and the Society of Sports Korean Medicine. To obtain academic approval, professional societies reviewed the academic and external feasibility, strict development, content validity, applicability, and the feasibility of recommendations. Academic certification results were submitted to the GKoM.The certification of CPG for traffic injuries was evaluated by a special review and assessment committee formed by GKoM members. After a systematic review of the South Korean medicine clinical procedures exhibiting methodological rigor and external validity, the CPG for traffic injuries obtained final certification from the GKoM under the auspices of NIKOM in 2020.The developing committee produced pamphlets, card news, and infographics regarding standardized Korean medicine treatment to increase the use of CPG for traffic injuries at clinical sites by both Korean medicine doctors and patients.After the reorganization process, the revised recommendations increased from 13 to 25 . Each reRecommendation 1: Collaborative medical treatment may be considered for patients of all ages suspected of having whiplash-associated disorder (WAD) III and WAD IV after a physical examination (GoR/LoE: C/very low). A survey of medical collaboration using TKM and conventional medicine in 2019 indicated that 80.5% of patients with traffic injuries thought that collaboration was necessary to enhance their treatment outcomes . South KRecommendation 2: Blood stagnation syndrome is the first pattern to occur after traffic injury for patients of all ages. Depending on the patient’s condition or the doctor’s judgment, more detailed pattern identification according to qi–blood, viscera–entrails, cold–heat, and yin–yang may be considered (GoR/LoE: C/very low). The frequency of the classification of TKM pattern syndrome according to two questionnaire surveys of Korean medicine doctors has been presented previously ,11. TKM Recommendation 3-1: A combination of usual care and acupuncture treatment should be considered instead of other usual care interventions for the improvement of neck pain experienced by patients with WAD I and WAD II (aged 19–70 years) (GoR/LoE: B/moderate). There was a statistically significant difference in pain  in the control group who received concurrent sham acupuncture and usual care and pain of the group that received usual care alone; however, there was no significant difference in disability  ,17,18. NRecommendation 3-2: The combination of usual care with acupuncture treatment may be considered for low back pain and function improvement in patients with WAD I and WAD II (aged 19–70 years) (GoR/LoE: C/very low). Acupuncture and electroacupuncture are common treatments for low back pain and function improvement in patients with traffic injuries in South Korea. Because no randomized controlled trials focused on the treatment of low back pain and disability with acupuncture, the LoE was rated very low. Based on the literature findings and clinical experience of the CPG development committee, it was assigned a grade of C.Recommendation 3-3: A combination of usual care and electroacupuncture treatment should be considered instead of other usual care interventions to improve neck pain experienced by patients with WAD I and WAD II aged 19–70 years) (GoR/LoE: B/moderate). Concurrent treatment with electroacupuncture and usual care substantially reduced neck pain compared with sham electroacupuncture or usual care for adults ; however, there were no significant differences in the disability index  –70 years. SeveralRecommendation 3-4: The combination of usual care with additional electroacupuncture treatment may be considered for symptom improvement of low back pain for patients with WAD I and WAD II (aged 19–70 years) (GoR/LoE: C/low). The combination of usual care with additional electroacupuncture treatment did not provide significant improvement of the pain  or disability index  . The devRecommendation 3-5: The combination of usual care with the motion-style acupuncture technique (MSAT) should be considered instead of other usual care interventions to improve neck pain experienced by patients with WAD I and WAD II (aged 19–70 years) (GoR/LoE: B/moderate). The MSAT is a TKM technique that reduces musculoskeletal pain by combining breathing exercises and acupuncture treatment . For patRecommendation 4-1: Pharmacopuncture may be considered instead of acupuncture treatment alone for the alleviation of neck and low back pain experienced by patients with WAD I and WAD II (aged 19–70 years) (GoR/LoE: C/very low). Pharmacopuncture combines the principles of meridians and pharmacotherapy and is widely used at TKM institutions. No clinical study found that pharmacopuncture has a better therapeutic effect on neck pain or low back pain after traffic injuries than usual care or sham pharmacopuncture alone. However, because it is currently included in the medical coverage provided by auto insurance in South Korea, the CPG development committee assigned a GoR of C based on clinical experience and the literature.Recommendation 4-2: The combination of pharmacopuncture with usual care instead of acupuncture treatment alone should be considered for the improvement of neck pain for patients with WAD I and WAD II (aged 19–70 years) (GoR/LoE: B/moderate). Three trials that compared pharmacopuncture and usual care with acupuncture treatment alone for neck pain after traffic accidents included pain intensity and disability index assessments. Three studies found statistically significant differences in pain intensity when pharmacopuncture was used in combination with usual care  ,25,26. ORecommendation 4-3: The combination of pharmacopuncture with usual care may be considered for the improvement of low back pain experienced by patients with WAD I and WAD II (aged 19–70 years) (GoR/LoE: C/very low). The LoE was rated as very low because it included only one study. Even though a small number of trials failed to find statistically significant effects on the pain intensity  and disability index , concurrent pharmacopuncture treatment was frequently used for low back pain alleviation and function recovery after traffic accidents. The CPG development committee assigned a GoR of C [Recommendation 5-1: CMT alone may be considered to alleviate neck pain and improve the function of patients with WAD I and WAD II (aged 19–70 years) (GoR/LoE: C/very low). CMT is popular in South Korea, where other manipulation methods, such as osteopathy, chiropractic, and other manipulative therapies, were developed . HoweverRecommendation 5-2: The combination of CMT with usual care may be considered for the improvement of neck pain for patients with WAD I and WAD II (aged 19–70 years) (GoR/LoE: C/low). When a control group who received concurrent CMT with usual care was compared with a group who received usual care alone, there was no statistically significant difference in pain  or disability  ,30. HoweRecommendation 5-3: A combination of CMT with usual care may be considered for the improvement of low back pain experienced by patients with WAD I and WAD II (aged 19–70 years) (GoR/LoE: C/low). One study found a significant difference in the pain index when comparing patients with back pain induced by traffic accidents treated with CMT plus usual care and patients treated with usual care alone  . No seriRecommendation 6-1: Moxibustion alone may be considered for the alleviation of neck and low back pain experienced by patients with WAD I and WAD II (aged 19–70 years) (GoR/LoE: C/very low). No clinical study has found that moxibustion alone has a better therapeutic effect on neck or low back pain after traffic injuries than usual care or placebo alone. Hence, the CPG development committee set the LoE as low. However, a GoR of C was assigned because moxibustion is frequently used in South Korean clinical settings to alleviate neck and low back pain intensity and function recovery.Recommendation 6-2: The combination of moxibustion (indirect) with usual care may be considered instead of usual care alone for neck pain experienced by patients with WAD I and WAD II (aged 19–70 years) (GoR/LoE: C/low). Compared to usual care alone, routine care combined with moxibustion substantially relieves neck pain and improves the function of adult patients  . A previRecommendation 6-3: The combination of moxibustion (indirect) with usual care may be considered for improving low back pain experienced by patients with WAD I and WAD II (aged 19–70 years) (GoR/LoE: C/very low). No clinical study has found that concurrent treatment with moxibustion and usual care improves low back pain after traffic injuries. Despite the lack of clinical research corresponding to the CQ, the development committee assigned a GoR of C and a very low LoE based on the literature and the clinical experience of the CPG committee.Recommendation 7: Cupping alone or concurrent therapy with cupping and usual care may be considered for patients with WAD I and WAD II (aged 19–70 years) to improve neck and low back pain and function (GoR/LoE: C/very low). No clinical study has found that cupping therapy alone results in improved neck and low back pain and function after traffic injuries. A GoR of C and a very low LoE were assigned based on South Korea’s clinical settings, the literature, and the clinical experience of the CPG development committee.Recommendation 8: Korean medicine physiotherapy alone or combined with usual care may be considered for patients with WAD I and WAD II (aged 19–70 years) to improve neck and low back pain and function (GoR/LoE: C/very low). No clinical study has found that Korean medicine physiotherapy alone or in combination with usual care results in improved neck and low back pain and function after traffic injuries. A GoR of C and very low LoE were assigned based on South Korea’s clinical settings, the literature, and the clinical experience of the CPG development committee.Recommendation 9: Herbal medicines alone or in combination with usual care according to pattern identification may be considered for patients with WAD I and WAD II (aged 19–70 years) to improve neck and low back pain and function (GoR/LoE: C/very low). No randomized controlled trial has shown that herbal medicine alone or in combination with usual care results in improved neck and low back pain and function after traffic injuries. The frequency of herbal medicine use has been evaluated using questionnaire surveys completed by Korean medicine doctors . A GoR oRecommendation 10: Korean medicine treatments alone or in combination with usual care may improve pain and function of patients (aged 19–70 years) with fractures caused by traffic accidents (GoR/LoE: C/very low). No large-scale clinical trials that satisfied the CQs have been performed, and only a few simple case reports have been published. TKM is frequently used in combination with usual care to treat fractures caused by traffic accidents to provide conservative treatment or rehabilitation, and better results can be expected. Therefore, the CPG development committee assigned a very low LoE and a GoR of C based on the current state of TKM and expert agreements.Recommendation 11: Korean medicine treatment alone or in combination with usual care may improve psychological symptoms experienced by patients (aged 19–70 years) with acute stress disorder and post-traumatic stress disorder (PTSD) after traffic accidents (GoR/LoE: C/very low). A survey of the prevalence of acute stress disorder and PTSD for patients after traffic injuries and the validity of screening tests conducted by the development committee found that the stress response after traffic accidents often leads to PTSD . FurtherRecommendation 12-1: The combination of CMT and pharmacopuncture may be considered instead of CMT alone or pharmacopuncture alone to improve neck and low back pain experienced by patients with WAD I and WAD II (aged 19–70 years) (GoR/LoE: C/very low). Regarding low back and neck pain induced by a traffic accident, no randomized, controlled trials have compared the concurrent treatment of CMT and pharmacopuncture to CMT alone and pharmacopuncture alone. According to the results of a survey of Korean medicine doctors conducted in 2016, CMT and pharmacopuncture were often used simultaneously, and 58.4% of the respondents reported that concurrent CMT and pharmacopuncture were not covered by insurance in South Korea. Although no study matching the CQ was found, a very low LoE and a GoR of C were assigned based on the literature and the clinical experience of the CPG development committee.Recommendation 12-2: The combination of pharmacopuncture with usual care  may be considered instead of usual care to improve neck pain experienced by patients with WAD I and WAD II (aged 19–70 years) (GoR/LoE: C/low). One study reported that compared to usual care alone, the combination of pharmacopuncture with usual care substantially relieved neck pain  . BecauseRecommendation 12-3: The combination of CMT with usual care  should be considered instead of usual care alone for improving neck pain experienced by patients with WAD I and WAD II (aged 19–70 years) (GoR/LoE: B/moderate). Compared with usual care alone, concurrent CMT with usual care substantially relieves neck pain  . When thRecommendation 13: Korean medicine treatment alone or concurrent treatment with usual care may improve the rate of return to normal life and work for patients with traffic injuries (GoR/LoE: C/very low). Although several survey studies have been performed, no clinical trials have found matching rates of returning to life and work associated with TKM treatment alone and with concurrent treatment with usual care. According to a survey of Korean medicine doctors in 2016 and 2017 and another survey of patients with traffic injuries in 2018, patients (65.7%) and Korean medicine doctors (31.4%) indicated that the severity of the traffic accident was a factor affecting the prognosis for patients ,11,15. Thttp://www.nckm.or.kr, accessed on 12 November 2021).The CPG development committee produced and distributed CPG infographics to the community of Korean medicine doctors during annual academic conferences. It also produced and distributed online branding card news and patient handouts to the general public in 2020 . AdditioTraffic accidents have costly consequences. Medical expenses for traffic accidents in Korea have increased to KRW 2.337 trillion (approximately USD 20 billion) and are steadily increasing. The increase in medical expenditures associated with traffic accidents has also resulted in social and economic costs. In South Korea, where a binary healthcare system exists, the number of Korean medical institutions for traffic accident patients has continuously increased since 2016, when the research and development of TKM CPG began. These institutions are responsible for half of all traffic accident medical expenses. As a result, the demand for standardized treatment was always increased as the number of traffic accident injury patients accessing Korean medical institutions grows, as does medical expenses.There are clear limitations to applying conventional treatment when there is no clear reason for its use despite the inconvenience of pain or poor function after traffic accidents. After a traffic accident, pain and other problems can exist despite the absence of damage to the musculoskeletal system or nervous system. However, there is a limit to the application of conventional treatment for symptoms, such as dizziness and pain. Therefore, patients with traffic injuries may benefit from diagnosis and therapy using TKM, which combines the total structure and function of the body based on individual constitutional traits. Because many patients with traffic injuries are satisfied with the treatment and management provided by TKM institutions, the number of patients opting for TKM is increasing. Moreover, patients who experience pain that persists after treatment at other medical institutions often resort to TKM treatment.Various CPGs address traffic accidents in other countries; however, in South Korea, none existed. South Korea has a unique medical system divided into conventional medicine and TKM. Although the need for standardized and systematic guidelines has steadily increased in South Korea, Korean medicine doctors consisting of methodological and clinical experts have not gathered to prepare CPG for traffic injuries that consider TKM until now. For this reason, about 50 CPG related to TKM are being developed under the guidance of the South Korean government. The CPG for traffic injuries were created to focus on the therapeutic concepts that Korean medicine doctors expect to enhance the clinical application of Korean medicine treatments on a practical level, including acupuncture, pharmacopuncture, and CMT for patients with traffic injuries. The CPG was developed based on the research methodology used for treatment guidelines, and recommendations were made based on various CQs related to traffic accidents. Compared to interventions currently used by Korean medicine doctors, more standardized treatment methods are recommended by the CPG. This is significant for creating treatment procedures and a cost-effective TKM treatment system on national and international levels. This CPG for traffic injuries have been approved by relevant professional Korean medicine societies and the GKoM, demonstrating their usefulness.Since 2016, when the de novo development of CPG for traffic injuries using GRADE methodology began, there have been numerous recommendations with unacceptable GoRs and insufficient LoEs because of the lack of relevant medical literature. The development committee has addressed these constraints by organizing and commencing multi-center, randomized clinical trials and submitting research papers for publication. It was necessary to search for evidence in the literature, including studies other than randomized, clinical trials, to support clinical considerations before the CPG could be adapted. However, more systematic and well-designed clinical studies are required to confirm the adapted CPG.De novo CPG for traffic injuries was approved and published in 2018, and the adapted CPG for traffic injuries were certified in 2020. However, two surveys conducted after the de novo CPG found that it was difficult to communicate and promote this CPG to TKM doctors at clinical sites. Therefore, the development committee has tried to communicate and promote the updated CPG through various domestic and international conferences, card news, infographics, and leaflets to inform TKM doctors of the systematic treatment procedures. Additionally, the following attempts were made to convey the patients’ perspectives. Qualitative and retrospective studies of the experiences of patients with traffic injuries and a search of the literature were performed. Surveys of patients visiting TKM institutions in South Korea have also been conducted to reflect patients’ opinions of the adapted CPG. Furthermore, a poll found that medical practitioners need to provide appropriate information, such as the precise diagnosis and treatment techniques to the patients; therefore, this was cited as a recommendation and clinical consideration.This CPG has a few limitations. First, it is difficult to develop evidence-based CPG based on standardized diagnosis and treatment principles because diagnoses vary according to individual patient characteristics, constitutions, and symptom patterns. Thus, the majority of evidence is insufficient to support recommendations due to the lack of well-designed RCTs. Additionally, regional constraints, with most of the studies taking place in China or South Korea, lead to some difficulty in developing evidence-based CPG. More well-designed RCTs are required. Therefore, it was difficult to adequately reflect the clinical reality of TKM using only existing clinical research methods.The second limitation of CPG is that conducting clinical research to generate evidence is frequently challenging because of institutional constraints. Additionally, it was not possible to objectively evaluated whether the dissemination brochures, infographics, and online branding news were sufficiently delivered to patients or TKM doctors.One of the strengths of this study was the continuous searching and updating of evidence after the de novo development of CPG. In addition, the CPG aims to synthesize and describe research findings to best reflect the characteristics of TKM. This guideline will be recommended widely for use and provide evidence for areas that need to be supplemented through step-by-step research in the future. This CPG will assist in increasing the treatment efficacy of TKM as it is disseminated to actual clinical settings, thus increasing the clinical application of TKM.We revised and updated the previous CPG for traffic injuries to include TKM and disseminated them in various ways so that they can be used by more TKM doctors. This guideline is the only CPG for patients with traffic injuries treated with TKM. The adapted CPG will be widely used in clinical practice and enhance the reliability of TKM to strengthen national insurance coverage in South Korea. We expect this CPG will contribute to all practitioners using similar interventions, including acupuncture, moxibustion, CMT, and cupping.


People with chronic neck pain show decreased endurance and strength of cervical muscles with compromised respiratory function. There is little evidence that improvement in breathing function of people with neck pain can help in enhancing cervical muscle strength and pulmonary function. The objective of this our clinical trial was to examine the effects of breathing re-education combined with physiotherapy on endurance and strength of deep neck flexors, and pulmonary function in patients with chronic neck pain.n = 15), and Group B, breathing re-education (n = 15). The duration of intervention was eight weeks with treatment five days a week. The endurance was measured with the craniocervical flexion test, strength with a handheld dynamometer (Baseline USA) and pulmonary functions with the Spiro lab 4 (USA) at baseline, at week four and at week eight of the intervention.In this double blind randomised clinical trial, 30 patients with chronic neck pain (25–50 years old) were randomly allocated to two groups. Group A, physiotherapy (p = 0.0001 and p = 0.0200 (p ˂ 0.05) respectively. Intergroup comparisons showed no significant differences for endurance, cervical extensor strength, Forced Expiratory Volume in one second (FEV1), and FEV1/FVC percentage.There was a significant between group improvement in the strength of deep neck flexors and forced vital capacity (FVC) in Group B Our study concluded that breathing re-education combined with other physiotherapy management is effective for improving the strength of neck flexors and increasing FVC in people with chronic neck pain.Breathing re-education may be part of physiotherapy management in patients with chronic neck pain.https://www.irct.ir/trial/46240.Iranian Registry of Clinical Trials, IRCT20200226046623N1,  Chronic neck pain is a common disability and is an important health problem in the general population. A systematic analysis of the global burden of disease reveals that the annual prevalence of neck pain is increasing with the highest burden in Europe, Africa and the Middle East . The trial was conducted according to the consolidated standards of reporting trial CONSORT guidelines , who had non-specific neck pain for more than 3 months, participated in our study. Data were collected from the patients attending the physiotherapy department district headquarter hospital Faisalabad, Pakistan during the period August 2020 to December 2020. Patients with upper cervical symptoms  and post-traumatic neck pain were excluded due to possible influences on the outcome measures during assessment and intervention procedures   Duymaz . A diffe) Duymaz .Blocked randomisation was done using concealed allocation and patients were randomly divided into two groups, Group A and Group B in 1:1. Group A with 15 patients , mean age was 38.54 years, received physiotherapy consisting of infrared radiation (IRR) over the cervical region in prone for 10 min followed by isometric exercises for flexors and extensors of the cervical spine in supine with a 10 s hold for each muscle group; 20 repetitions were performed. The physiotherapy was followed by sham breathing exercises for 15 min. For sham breathing exercises, each patient was instructed to lie in supine and place one hand on the chest and the other hand on the belly or navel region and breathe in their normal manner. The sham intervention was chosen as the best possible similar intervention available and was not expected to reproduce the effects of breathing exercises. In Group B, there were 15 patients , mean age was 38.42 years, who received both physiotherapy (as for Group A) and supervised breathing exercises focusing on proper inhalation, exhalation and chest expansion for 15 min. Each patient was instructed to place one hand on the chest and the other hand on the belly or navel region, inhale slowly through the nose for 5 s – 8 s, and exhale slowly through the mouth relaxing the chest wall and the abdomen. The duration of each session was 30 min and the total treatment time for both groups was the same. Patients in both groups received the intervention five days a week for a consecutive eight weeks. The intervention was conducted by a senior physiotherapist with more than 10 years’ experience in musculoskeletal and cardiopulmonary physiotherapy. All the outcome measures were assessed by an independent assessor blinded to group allocation.Cervical muscle endurance was measured with the Craniocervical Flexion Test as described by Jull et al. . This isCervical muscle strength was measured with a handheld dynamometer (Baseline Lite 200 lb) which has good interrater and intrarater reliability . Two pulmonary tests were performed, namely, (1) VC manoeuver, and (2) Forced Expiratory Technique (FET). This manoeuver included measurement of the Forced Expiratory Volume in one second (FEV1), Forced Vital Capacity (FVC) and FEV1/FVC percentage .The Shapiro-Wilk test was used to test the normality of the data, and data were normally distributed. Descriptive statistics are displayed as means and standard deviations. The two-way repeated-measures analysis of variance (ANOVA) was used to analyse and compare differences between groups (Group A vs. Group B). The statistically significance level was accepted at https://www.irct.ir/trial/46240. After ethical approval from the University of Lahore, permission was also obtained from the Independent University Hospital Faisalabad for data collection. Written informed consent in Urdu and English was taken from each participant prior to our study.Our study was approved by the Ethical Review Committee of the University of Lahore, Pakistan, reference number: IRB/UOL/FAHS/697/2020. Trial registration: IRCT 20200226046623N1 The 30 participants completed the 8-week intervention in our study, and none were lost to follow-up. There were no significant differences between groups in the mean age and Body Mass Index (BMI), endurance, strength of neck muscles and pulmonary function. Tabular representation of baseline characteristics is given in There was no noticeable difference between groups in the pre-intervention values of endurance, strength of cervical flexors, extensors FEV1, FVC and FEV1/FVC percentage. A two-way repeated measures ANOVA was performed to compare the effect of treatment given to Group A and Group B on endurance, strength of neck flexors and extensors, and pulmonary function.p = 0.0012). The endurance and strength of neck extensors had no between-group differences ,  ;  .p = 0.020) for Group B (breathing reeducation group). Forced Expiratory Volume in one second and FEV1/FVC percentage had no between-group differences ,   .The details of the pair wise comparison of the variables at different time points are given in Our study explored the effects of breathing re-education on the endurance and strength of the deep neck flexors and pulmonary function in patients with chronic neck pain. Our results showed that only cervical flexor muscle strength and FVC were significantly improved in Group B (breathing re-education group) as compared to Group A. The overall improved strength of cervical muscles in chronic neck pain patients may lead to less disability and improved quality of life. The improvement in VC will lead to more oxygen available to the neuromuscular system and may lead to less stress and less pain in patients with chronic neck pain.r = 0.45 and 0.42) and neck muscle endurance (rS = 0.36) .Our results are similar to a study to observe the immediate effects of breathing re-education on pain and muscle activation of patients with neck pain (Yeampattanaporn et al. In another study, breathing re-education combined with neck stabilising exercises resulted in improvement of respiratory function in patients with stroke. In the said study, 45 patients with stroke who were divided into three groups underwent a six-week breathing re-education programme. Outcome measures were deep neck flexor thickness measured through electromyography and respiratory function measured through spirometry (Lee & Hwang-Bo Kang et al.  investigIn another study on 40 healthy men, breathing exercises combined with dynamic upper extremity exercises resulted in improved FVC and FEV1. The 40 participants were divided into two groups, both groups received breathing exercises and the experimental group performed breathing exercises combined with dynamic upper extremity exercises. It was a four-week intervention programme and FVC increased significantly in both groups but between group analysis showed there was no difference in FEV1 before and after the intervention (Han & Kim The overall findings of our study showed that breathing re-education resulted in improved cervical flexor muscle strength and improved FVC. This regime may be used as an adjunct treatment with superficial heat and cervical muscle strengthening in people with chronic neck pain.One of the limitations of our study was that we only measured FEV1 and FVC. Measurement of other parameters of pulmonary function such as total lung capacity and residual volume may give more insight into the effect of breathing re-education on pulmonary function in people with chronic neck pain. Another limitation is the treatment duration, that is, five days a week for eight weeks. The treatment duration was difficult for the patients to comply with, and this may present a barrier to implementation. Our study was conducted in a single setting only; multicentre large-scale trials are needed to consider breathing re-education as a regular part of the multimodal treatment programme in the treatment of chronic neck pain.In conclusion, our findings suggest that breathing re-education combined with other physiotherapy management improves strength of neck flexors and FVC in people with chronic neck pain. Good respiratory technique and improved strength of neck flexors may lead to less fatigue, less pain experienced and possibly improved quality of life in these patients. Thus, breathing re-education may be an important regime to include in the treatment of people with chronic neck pain.


There were no significant differences in pressure pain threshold and numeric rating scale scores between the groups after surgery. The pain threshold decreased significantly in both groups at 3 h postoperatively compared to preoperative values, and recovered at 24 h. Co-administration of both opioids caused hyperalgesia regardless of fentanyl dose.Fentanyl and short-acting remifentanil are often used in combination. We evaluated the effect of intraoperative opioid administration on postoperative pain and pain thresholds when the two drugs were used. Patients who underwent gynecological laparoscopic surgery were randomly assigned into two groups (15 patients each) to receive either sufficient (group A) or minimum (group B) fentanyl . The estimated effect site concentration at the end of surgery was adjusted to the same level (1 ng/mL). Patients in both groups also received continuous intravenous remifentanil during surgery. The primary outcome was the pressure pain threshold, as evaluated by a pressure algometer 3 h postoperatively. The pressure pain threshold at 3 h postoperatively was 51.1% (95% CI: [44.4–57.8]) in group A and 56.6% [49.5–63.6] in group B, assuming a preoperative value of 100% ( Opioids are widely used analgesics in both, acute pain (such as during surgery) and chronic pain (as in cancer) ,2. ChronFentanyl has been used as an analgesic opioid for acute pain during and after surgery. Postoperative hyperalgesia has been found to be more common in patients administered 100 μg/kg of intraoperative fentanyl after cardiac surgery than in those administered 10 μg/kg . In a stAnesthesiologists often use remifentanil in combination with fentanyl, although the methods of administration are disparate and appear to be unfounded. The notion of preemptive analgesia, that involves administration of sufficient amounts of opioids prior to surgical invasion to reduce postoperative pain, often influences decision-making . HoweverIn this study, we compared the pain threshold and pain perception between patients receiving sufficient dose of fentanyl with higher maximum effect site concentration and sparing doses with lower maximum effect site concentration during surgery, in combination of remifentanil infusion. Both cases received fentanyl intraoperatively with an estimated effect site concentration of approximately 1 ng/mL at the end of surgery, offering analgesic effect without respiratory depression. We evaluated postoperative pain threshold and pain complaints, and discussed the effective use of two types of opioids with different half-lives in surgical anesthesia.http://www.consort-statement.org accessed on 21 June 2022).This single-center, prospective, randomized, controlled, clinical trial included two parallel groups of patients who underwent gynecological laparoscopic surgery between January 2019 and October 2020 at the Teikyo University Chiba Medical Center, Ichihara, Japan. The study was performed in accordance with the Declaration of Helsinki, and was approved by the Teikyo University Ethical Review Board for Medical and Health Research Involving Human Subjects . The study was prospectively registered in the University Hospital Medical Information Network Clinical Trials Registry . All participants provided written informed consent to participate in the study and approved the publication of a study report. This manuscript adheres to the applicable CONSORT guidelines ; this was performed by the secretary under the supervision of an independent researcher. Sealed envelopes containing the group allocation and study number details were opened on the day of the operation. The patient and investigators who evaluated the pain intensity and threshold were blinded to group allocation. An independent anesthesiologist opened the sequentially numbered envelope containing details regarding randomization assignment, and administered general anesthesia according to the protocol. Female patients in their 20s to 50s with benign ovarian or uterine disease, who were scheduled for laparoscopic surgery under general anesthesia were eligible for participation in the study if they had American Society of Anesthesiologists (ASA) physical status classification scores of I  or II (with mild systemic disease). Patients were not eligible if they were pregnant or breastfeeding, had cognitive impairment with difficulties in pain evaluation, had any contraindications to use of the drugs included in the protocol, or had a history of chronic opioid use before surgery. There was no particular weight limit for the patient, but the smaller value between the actual body weight and the ideal body weight, 22 × (height in m)The standardized intraoperative protocol was followed in both groups; opioids were additionally administered as per the study requirements. General anesthesia was induced and maintained by targeted controlled infusion of propofol   at an efRemifentanil was administered at a rate of 0.2 μg/kg/min from the induction of anesthesia to the end of surgery in all patients. Patients assigned to group A (sufficient dose of fentanyl administration) received 6 μg/kg fentanyl intravenously at the start of surgery; fentanyl administration was continued as an intravenous infusion at a rate of 0.5 μg/kg/h until the end. The maximum effect site concentration was expected to be 7.86 ng/mL, and the effect site concentration after 3 h of surgery was expected to be approximately 1.0 ng/mL. Patients assigned to group B (minimum dose of fentanyl administration) received 1 μg/kg of fentanyl intravenously at 60 min after the start of surgery; fentanyl administration was followed by continuous intravenous administration at a rate of 1.0 μg/kg/h until the end. Patients also received 2 doses of fentanyl intravenously at a dose of 0.5 μg/kg at 90 and 120 min after the start of surgery. The maximum effect site concentration was expected to be 1.5 ng/mL, and the effect site concentration after 3 h was expected to be approximately 1.0 ng/mL . The effPressure Pain ThresholdThe following outcome variables were evaluated:2. The evaluator applied force to the tip of the index finger of the patient, and measured the value when the patient felt pain; this was repeated thrice. The average value (kg/0.5 cm2) was used as the pressure pain threshold value. The value of the right or left hand that was able to be measured at the bedside after surgery was compared with the preoperative value on the same side.The pressure pain threshold  was meas2.Numeric Rating Scale scoreThe numeric rating scale evaluates the degree of pain in 11 stages ranging from 0–10, with 0 indicating no pain at all and 10 indicating the worst pain possible . The eva3.Total recorded dose of fentanyl administered during surgery.4.The highest value during surgery and the value at the end of surgery for the effect site concentration of fentanyl, as estimated by pharmacokinetic simulation .5.Number of analgesics  administered in the hospital room until 24 h after surgery, based on the medical records.Difference between the two groups in terms of the pressure pain threshold value at 3 h after the end of surgery, assuming that the value on the day before surgery was 100%. Difference between the two groups in terms of pressure pain threshold value at 24 h after the end of operation.Difference between the two groups in terms of numeric rating scale scores at 0–3 h, 3 h, and 24 h after the end of operation.Difference between the two groups in terms of the frequency of analgesic  use in the hospital room during 24 h after surgery.Changes in postoperative pressure pain threshold and numeric rating scale score values in each group compared to those before surgery.2, mean ± SD, n = 30)  and 56.6% [49.5–63.6] in groups A and B, respectively, assuming a preoperative pressure pain threshold value of 100% . Pressure pain threshold values at 24 h after surgery were 133.5% [108.2–158.8] and 138.0% [110.5–165.5] in groups A and B, respectively . Numeric rating scale values in groups A and B were 3.3 [2.3–4.3] and 4.7 [3.7–5.7], respectively, at 3 h after surgery , and 2.2 [1.3–3.1] and 3.1 [1.9–4.3], respectively, at 24 h after surgery . There was no significant difference in the frequency of additional analgesics used during 24 h after surgery . Most patients in both groups did not feel any pain before surgery . The numeric rating scale values were high immediately after surgery (during 0–3 h) and decreased significantly in both groups after 3 and 24 h  . HoweverUntil 3 h after returning to the hospital room, some patients complained of pain and were administered analgesics by intravenous infusion. This occurred because the effect of local infiltration anesthesia had diminished and the effect site concentration of fentanyl had decreased. There was no significant difference between the two groups in terms of highest numeric rating scale values during 0–3 h after surgery, and in the numeric rating scale and pressure pain threshold values at 3 h and 24 h after surgery. In both groups, the pressure pain threshold values were reduced significantly at 3 h after operation compared to those before operation; this indicated that hyperalgesia was induced. In all cases, the pressure pain threshold was evaluated at the fingertip where the patient did not feel spontaneous pain. The innervated spinal cord segment was also separate from the surgical wound. Therefore, the patient could have suffered systemic hyperalgesia by central sensitization ,24. In rWe waited for complete anesthetic recovery and measured the pressure pain threshold at 3 h after surgery in this study. The maximum numeric rating scale score perceived during 0–3 h was also assessed at that time. Pressure pain threshold values may have been lower immediately after surgery, when the numeric rating scale scores were high. Hyperalgesia may be evaluated in further detail by alternative tests such as the cold pain pressor model and electrical stimulation . HoweverThe scope of this study is limited by that fact that both groups received remifentanil in combination to ensure adequate analgesia during surgery. As both remifentanil and fentanyl cause analgesia and hyperalgesia via μ opioid receptors, it is not clear which drug caused hyperalgesia in this study. Continuous administration of remifentanil at a rate of 0.2 μg/kg/min/ results in a predicted effect site concentration of approximately 4.4 ng/mL (Minto model) during surgery . The maxInappropriate use of opioid analgesics has had a serious impact on society in recent years ,27,28,29The potential disadvantages of opioid use during the perioperative period include the triggering of chronic use  and impaDifferent doses in fentanyl administration during surgery in addition to continuous remifentanil infusion did not significantly affect postoperative pain thresholds and numeric rating scale scores. Combined administration of both opioids caused hyperalgesia after surgery. Offering adequate analgesia is essential by appropriately adjusting the dose of analgesics based on the patient’s needs.


Patients with CDC category A showed moderate to high correlations among HRQL, pain and sleep. In CDC B-type patients, a moderate correlation was observed between pain and mental health. In CDC C patients, moderate correlations were observed between HRQL and sleep and pain and sleep, with no correlations between HRQL and pain. Conclusions: HRQL, pain and sleep are differently correlated in HIV patients depending on their clinical stage. Neither the nadir of CD4-T cells nor the current count of CD4-T cells was found to be related with HRQL, pain or sleep.Introduction: Health-related quality of life (HRQL), pain and sleep have been described as relevant traits in patients with human immunodeficiency virus (HIV). The aim of this study is to describe and evaluate HRQL, pain and sleep and their interdependence in HIV-positive patients. Methods: A cross-sectional study on HIV-infected patients was conducted. A set of five different questionnaires was used: two questionnaires addressing HRQL , one on pain (McGill Pain Questionnaire) and one on sleep . We also collected the sociodemographic and clinical characteristics of patients. Results: The sample included 109 patients . The pain experience was independent of HRQL and sleep. Relationships among HRQL, pain and sleep associated to sociodemographic and clinical factors were not detected ( In 2013, human immunodeficiency virus (HIV) had a prevalence of 34 million people infected throughout the world, with an estimated incidence of 2.5 million cases in 2012  questionPain in patients with HIV has been shown to be extremely prevalent (between 40 and 60%), and the syndromes and causes of pain in out-patients with acquired immune deficiency syndrome (AIDS) have been documented too ,8. FurthSleep alterations are common in a high percentage of patients with HIV, ranging between 56%8 and 76% . They coNevertheless, the relationships among HRQL, pain, sleep and other clinical parameters are not well established. Accordingly, the present study aims to describe HRQL, pain and sleep and their relation with clinical and sociodemographic variables in HIV-positive patients in a follow-up scheme at a tertiary care service in Salamanca (Spain).A cross-sectional study with a non-probabilistic sampling of consecutive cases was designed. This was implemented in patients positive for HIV at the University Hospital in Salamanca (Spain), a reference hospital for 350,000 inhabitants, between November 2011 and January 2012.Sample recruitment was performed through a proposal by the physician after completing a routine consultation. In case of acceptance, patients were informed as to the nature of this study, and informed written consent was obtained. A single trained observer collected the data individually from each patient. This study was approved by the Bioethics Committee of the University of Salamanca.The criteria for inclusion in this study were as follows: the patient is diagnosed with HIV, the patient is receiving treatment at the consultancy of infectious diseases, the patient is aged above 18 and the patient signed a consent form to participate in this study. Exclusion criteria were less than 6 months from diagnosis, cognitive disorders involving comprehension and/or communication, and refusal to participate in this study.The following sociodemographic and clinical variables were collected for this study: sex, age, weight, height, body mass index (BMI), educational level, marital status, domestic situation, income, employment status, substance abuse, treatment with methadone, months after diagnosis, HIV transmission practice, CDC category (expression of infection severity and progression), current CD4-T cell count, nadir of CD4-T cells, peak viral load, current viral load and opportunistic diseases.HQRL was analyzed using the Spanish validated Short Form 36 Health Survey (SF-36). This is divided into 36 items grouped in 8 domains, namely: physical functioning, physical role, bodily pain and general health  score), vitality, social functioning, emotional role and mental health  score). The score ranges between 0 points for a low level of HQRL and 100, indicating a high HQRL level. It has a high internal consistency (Cronbach’s α = 0.7), and its test–retest reproducibility is between 0.58 and 0.99 .We also applied the Medical Outcomes Study Short Form 30 (MOS-SF-30) specific for HIV. This is divided into 22 items and subdivided into 11 domains: general health perception, physical functioning, role functioning, social functioning, cognitive functioning, pain, mental health, energy/fatigue, health distress, quality of life and health transition. Scores ranged between 0 points for a low HRQL level and 100 points, indicating a high HQRL level. The questionnaire has a high consistency (Cronbach’s α = 0.78–0.89), and its test–retest reproducibility ranges between 0.58 and 0.85 .The Spanish version of the McGill Pain Questionnaire (MPQ), divided into 64 descriptors organized into 19 items, was used to assess pain. Based on these items, the descriptors were hierarchized in order of intensity. The items were combined to achieve three domains: sensory (1–15), affective (16–18) and evaluative (19) as well as the sum of the three, called pain rating index (PRI). We also considered the number of words chosen by the patient (NWC) and the present pain index (PPI) with levels between 1 (slight pain) and 4 (pain was unbearable). The test showed a high consistency (Cronbach’s α = 0.84) .Finally, we used the Pittsburgh Sleep Quality Index (PSQI) in its Spanish version. This is divided into 19 items that analyze the determinant factors of sleep quality grouped in 7 domains: sleep quality, sleep latency, sleep duration, habitual sleep efficiency, sleep disturbance, use of sleeping medication and daytime dysfunction. A higher score than 5 indicated poor sleep quality. The PSQI has shown a satisfactory reliability coefficient (0.78), and the component-total score correlations were all significant (0.53–0.77) .2, the Student’s t test and ANOVA tests were used, as appropriate, as well as the Kolmogorov–Smirnov test to identify the normal distribution of the quantitative data (p > 0.05).For descriptive analyses, we calculated means and standard deviations of the quantitative variables. For qualitative variables, frequencies and percentages were used. To identify differences in the sociodemographic variables between patients, the statistical χTo analyze the behavior with respect to the domains of the HRQL variables, pain, and sleep, we performed a biplot of principal components. The information is presented as a chart showing the variables and individuals on the same plane. To interpret the factors according to the analyzed domains, the corresponding vector angle should be used. Smaller angles of the domain with the factor indicate a larger weight of that variable in the factor considered. In addition, the angles between domains indicate associations among them. Sharp and flat angles represent strong associations , and right angles indicate correlations close to zero. The number of factors chosen for the representation was made using the screen plot, selecting factors for which the greatest number of differences in the absorption of variance was observed. Ward’s cluster analysis was used to interpret the position of individuals on the biplot plane. The cluster was calculated by the coordinates of individuals from the biplot of principal components.Owing to the high number of domains chosen and their associated interdependences, a multivariate analysis of variance (MANOVA) with Roy’s max root test was carried out to analyze the differences between the most relevant factors  with respect to all the HRQL domains, sleep and pain. We then calculated Pearson’s r coefficient as an estimator of the size of the effect to analyze the associations among domains.Classical statistical analyses of the data acquired were performed using the JMP v.7 statistical package . The biplot of principal components and Ward’s cluster analysis were performed using MULTIBIPLOT  ,15.The level of significance was set to 0.05.p = 0.957). The CD4-T cell count ranged between 40 and 1355 (469.16 ± 255.96 units). For the nadir of CD4-T cells, the range was between 2 and 600 (154.47 ± 119.74 units). In 70.6% of the cases, the current viral load was undetectable. Some individuals had not completed primary school (11.9%) or a university education (12.8%), whereas the most common level was primary school (55%). Regarding their domestic situation, there were significant differences between sexes (p = 0.01) since men lived with relatives 12 times more often than women; five lived with friends (none of them a woman), and twice the number of men stated that they lived alone. Moreover, for each single woman, there were four single men, whereas for each widower man, there were six women (p < 0.01).A total sample of 121 consecutive patients was requested, of which 12 refused to join this study. Out of the 109 who accepted, 75 were men (68.8%). The mean age was 46.08 ± 10.49 years (range 21–79) with no significant differences between sexes  with men earning higher salaries (94.11% of the subjects earning more than 1500 €/month were men).The employment situation did not reveal differences between the unemployed, students, housewives, those working outside the home and pensioners. Monthly incomes differed as a function of sex (p = 0.046). The sex distribution according to the HIV transmission practice was not statistically significant, except in the homosexual group which lacked women for comparison. A total of 43.11% of the population had been intravenous drug users (IDU) (21.27% women); 15.60% were homosexual men; 39.45% were individuals infected in heterosexual relations (55.81% women) and 18.3% had been infected in other circumstances (Most patients in this study had a history of self-reported substance abuse (56%) without differences in sex. However, five times more men than women used methadone as substitutive therapy  (13.32 ± 13.54), NWC (6.44 ± 5.86) and PPI (1.67 ± 1.76), suggesting a heterogeneous presence of pain in these HIV patients.Overall, values for sleep showed little variation, although the variability in the data was high, both regarding the total score (7.14 ± 4.44) and some components, such as sleep duration (0.95 ± 1.15), habitual sleep efficiency, (1.07 ± 1.27), use of sleeping medication (0.95 ± 1.35) and daytime dysfunction (0.64 ± 0.86). The least compromised component was daytime dysfunction, while sleep latency and sleep disturbance were the most affected. Nevertheless, the mode never surpassed a value of 1. Results of these questionnaires are shown in In the biplot of principal components, the first two factors, represented by the axes, accounted for 80.91% of the overall variance. The biplot representation shows the global dependence structure among the different domains related to HRQL, pain and sleep. It may be observed that the HRQL domains were inversely associated to the sleep domain and, to a lesser extent, to the pain domains. A weaker positive relationship was present between sleep and pain. Although all domains define the two factors, the first one is determined more by the HRQL and sleep domains, while the second factor of the analysis is determined more by the pain-associated domains. Ward’s cluster method from the individual coordinates was used to analyze the disposition of individuals. Based on the disposition of the individuals on the chart, two classifications can be made. The first one is defined by the pain domains, and it divides the individuals into two differentiated groups: those without pain (cluster 1&2)) and those with pain (cluster 3&4). The second classification is determined by the HRQL and sleep domains and is defined by a slope from the left to the right side of the plot with individuals with a high HRQL and sleep quality (clusters 1&3) and those with a low HRQL and sleep quality (clusters 2&4) .p = 0.927; domestic situation: F = 0.783/p = 0.628, F = 0.984/p = 0.984; HIV transmission practice: F = 0.766/p = 0.155; and opportunistic diseases: F = 0.982/p = 0.967.The MANOVA Roy’s max root tests of the HRQL domains, sleep and pain between the groups defined by the sociodemographic and clinical factors did not find statistically significant differences dependent on the factors analyzed: sex: F = 0.976/None of the CD4-T cell variables showed correlations with HRQL, pain or sleep . A moderIn CDC A patients, strong inverse correlations were observed between HRQL components and MPQ variables and between HRQL components and PSQI, and moderate to high direct correlations were observed between MPQ variables and PSQI. The nadir of CD4-T cells and the current CD4-T cell count were moderately directly correlated.In CDC B patients, moderate inverse correlations were found only between MCS and MPQ variables and between MOS-SF-30 and PPI and PSQI. The nadir of CD4-T cells and the current CD4-T cell count were also directly correlated.Finally, CDC C patients showed a consistent trend of correlations between PSQI and HRQL and MPQ variables. They were direct between pain and sleep and inverse between HRQL and sleep. There were no correlations between HRQL and pain, and neither between CD4-T-cell data .The main aim of the present study is to describe and analyze the interrelationships of HRQL, pain and sleep with sociodemographic and clinical factors in a convenient sample of Spanish HIV patients. The observed changes in HIV infections in terms of the number of people affected, their sociodemographic characteristics as well as the distribution of infected individuals due to HIV transmission practices  determinResults of the HRQL, pain and sleep in the overall sample, which account for 80.91% of the total variance, show that only sleep and HRQL are related in this case inversely (a higher score on PSQI and a lower one on HRQL), while pain is a fluctuating experience independent of HRQL and sleep. The relationships between HRQL and HIV ,18 and bThe HRQL results were appreciably higher (more than 20 points for both the PCS and MCS) than those reported by López-Bastida et al. in Canary Islands patients (Spain) according to their immunological situation . In thatFew studies used MOS-SF-30 despite its good clinimetric characteristics before the current analysis . Our resThe use of a generic and an HIV-specific HRQL questionnaire was useful, as previously documented , in deteOur patients referred slight to moderate pain, while 40.4% of them referred no pain. These levels are in line with those described by Lee et al. . This loThe prevalence of sleep alterations in our patients (66.1% with PSQI > 5) lies within the reported parameters ,9. From The present study has methodological limitations. One of the main ones is the limited sample size used (109 patients). However, there are published surveys with a similar patient number that showed relevant evidence in this research area ,30. FutuThe results of our study show that, although pain appears as an independent experience, the relationship between HRQL, pain and sleep depend on the developmental stage of the disease in HIV-infected individuals. The greater the values of HRQL and sleep quality, the lower the values of pain observed in patients with CDC A and C, while in CDC B patients, only mental health is directly related to pain. No relationship was observed between the nadir of CD4-T cells or the current CD4-T cell count and HRQL, pain or sleep. Accordingly, although longitudinal studies are needed, the CDC category  should be considered when analyzing the HRQL state, pain and sleep in patients with HIV.


Regarding PPT values, a significant increase was found when comparing baseline data with post-treatment follow-ups (p < 0.05), and even though a significant decrease was found in muscle thickness when baseline values were compared with the 1- and 3-months assessments, no differences were found when compared with the 72 months follow-up (p > 0.05). A single injection of BoNT-A presents long-term effects in reducing pain in persistent MFP-TMD patients, and a reversibility of adverse effects on masticatory-muscle thickness.This study assessed the long-term effects of botulinum toxin type A (BoNT-A) in subjective pain, pain sensibility, and muscle thickness in persistent myofascial temporomandibular-disorder pain (MFP-TMD) patients. Fourteen female subjects with persistent MFP received BoNT-A treatment with different doses . The treatment was injected bilaterally in the masseter and anterior temporalis muscles in a single session. Clinical measurements included: self-perceived pain (VAS), pain sensibility (PPT), and muscles thickness (ultrasonography). Follow-up occurred 1, 3, 6, and 72 months after treatment for VAS and PPT and 1, 3, and 72 months for ultrasonography. For statistical analysis, the Friedman test with the Bonferroni test for multiple comparisons as a post hoc test was used for non-parametric repeated measures comparisons among the evaluation times. A 5% probability level was considered significant in all tests. VAS values presented a significant decrease throughout the study ( Myofascial pain (MFP) has been related to affect up to 95% of patients with chronic pain  and is rConsidering its high prevalence and chronicity, multidisciplinary approaches have been suggested for treatment. Although non-invasive conservative treatments should be considered as the first-choice intervention , dealingSeveral studies have reported the positive effects of BoNT-A in pain syndromes , such asHowever, studies evaluating improvements and adverse effects after BoNT-A’s applications in muscle pain conditions are limited to short-term follow-ups, which jeopardize findings regarding effectiveness . In addiFrom the initial 60 patients treated with BoNT-A, 14 individuals (23%) returned for the 6-year assessment . Even thp < 0.001). This pain reduction was maintained in subsequent examinations, with no significant differences until the 6-year evaluation (p > 0.05)  .p > 0.05). However, after three months there was a significant increase in PPT’s values compared with the baseline and the one-month assessment period (p < 0.001)  . This sip < 0.001). Although this reduction remained after 3 months, at the 6-year period it was not possible to observe any statistically significant difference from the baseline  in the first two periods of evaluation, after 6 years there was masticatory-muscle thickness recovery.The positive effects of BoNT-A in a variety of chronic pain conditions  have beeOur findings showed that a single injection of BoNT-A, regardless of the dose, already produced a significant improvement in terms of subjective pain after one month of evaluation and was sustained until the 6-year evaluation. Our findings are in line with reports demonstrating a decrease in subjective pain after BoNT-A injection in samples with the same characteristics as ours after 4  and 6 2 months oMoreover, one question remains unclear about the BoNT-A analgesic mechanism of action: is it predominantly peripheric or central? There is plenty of literature about the analgesic peripheral effects of BoNT-A ; howeverBoNT-A treatment is considered generally safe because the doses used for pain conditions are far from the lethal doses. In addition, a systematic review  reportedThe reduction in muscle thickness is part of a series of events produced when BoNT-A is injected. First, a muscle paralysis is caused by a neural denervation that lasts for at least three months , during Although our results demonstrated positive effects of a single injection of BoNT-A regardless of the dose, caution is suggested when judging the present findings since some limitations should be mentioned. The present study was performed on a convenience population, without sex comparison. Additionally, although the rate of patients who returned to the 6-year follow-up could be considered acceptable (23%), a larger sample size is required for future studies. Additionally, it cannot be excluded that factors such as the placebo effect, the natural evolution of the disease , and the regression toward the mean may also partially explain treatment outcomes. However, it is important to mention that the study population was composed of persistent MFP TMD patients that had suffered for at least 6 months , and thaBased on the results and limitations of this study, and considering the possible placebo effects on pain variable, it can be concluded that:A single injection of BoNT-A, regardless of dosage, could present long-term effects in reducing pain in persistent MFP TMD patients, that did not achieve significant pain relief using conservative therapies. There is a reversibility of adverse effects on masticatory-muscle thickness after a single injection of BoNT-A, which may be related to the number of times that the toxin is injected and not to the doses.The present clinical trial reports the 6-year follow-up results of a previous study  performen = 60) were contacted. The patients were recruited via telephone for the 6-year assessment. Therefore, subjects included in the present study were a convenience sample of the study of De la Torre Canales et al. (2020) , which aBoNT-A  was reconstituted using non-preserved sterile saline solution 0.9%. Bilateral intramuscular injections were performed using a 1 mL syringe with a 30-gauge and 13 mm needle. For each masseter muscle, doses from 30U to 75U were distributed in five sites 5 mm apart from each other and were injected in the inferior part of the muscle (on mandibular angle) after functional test (teeth clenching). For each anterior temporalis muscle, doses from 10U to 25U were distributed in five sites 5 mm apart from each other, which were determined according to the functional test considering the most prominent part, which had to be 1 cm external to the eyebrow. Injections were performed by a calibrated researcher during a single appointment. A visual analogue scale (VAS)  is a 100®, Cotia, São Paulo, Brazil). The algometer has a 1-cm2 flat circular-shaped tip at one end, which was used to apply pressure to the most prominent part  of the relaxed masseter and anterior temporalis muscles. The device was positioned perpendicularly to the muscles and applied with increasing and constant pressure of approximately 0.5 kgf/cm2 by a new single calibrated operator (Kappa = 0.89), which was blind for the injected groups. Patients were asked to press a button at the very beginning of pain sensation. The procedure was fully explained to each patient before the examination, and it was emphasized that the purpose of the study was to measure the PPT and not pain tolerance. PPT measurement sites were aligned with BoNT-A injections sites. The PPT was determined as the arithmetic mean of three measurements.Pressure-pain thresholds (PPT)  was measThe thickness of both masseters and anterior temporalis muscles during maximum voluntary contraction (MVC) was calculated using real-time ultrasound imaging . A different calibrated operator performed the 6-year measurement. The patients were placed in a supine position at a height that ergonomically favored the examination. Muscle thickness was measured directly on the instrument’s screen, with an accuracy of 0.01 mm according to the most voluminous part of the muscle in the screen image. UI values were determined as the arithmetic mean of three measurements .®, New York, NY, USA). A 5% probability level was considered significant in all tests.Subjective pain intensity (VAS) and PPT were assessed at five-time points: before treatment (baseline) and at one, three, and six months, as well as six years after treatment. Data from muscle thickness, measured with ultrasound imaging, were assessed at four-time points: before treatment (baseline), one and three months after treatment, and six years after treatment. The inter-rater reliability was assessed by the Intraclass correlation coefficient (ICC). The Kolmogorov–Smirnov test demonstrated no normal distribution. Then, the Friedman test with the Bonferroni test for multiple comparisons as a posthoc test was used for non-parametric repeated measures comparisons among the evaluation times. All data were analyzed using SPSS Statistics 25.0 software (IBM


V = .711 (p < .001), which can be taken as a strong relation between the tool and the diagnosis of the medical doctor. Besides, in 67.4% of the cases, the diagnosis was concordant. An overestimation of the severity of the diagnosis occurred more often than underestimation (15.1% vs. 7%). The app-based tool is a safe tool to support healthcare professionals in back pain diagnosis.The aim of this study is to show the concordance of an app-based decision support system and the diagnosis given by spinal surgeons in cases of back pain. 86 patients took part within 2 months. They were seen by spine surgeons in the daily routine and then completed an app-based questionnaire that also led to a diagnosis independently. The results showed a Cramer’s  Back pain is one of the leading reasons for people seeking for health care services . Thus, bThe aim of the present study was to redesign the questions and algorithm to improve the concordance between medical diagnosis given by a spinal surgeon and the algorithm tool.This non-randomized unblinded correlational study included male and female patients with back pain who visited the Department of Orthopaedics of the University Medical Centre Regensburg between September and November 2020. Inclusion criteria were: consultation because of back pain, German language to understand the questions. Exclusion criteria were missing consent or patients who were not able to take part because of other medical reasons. The study was approved by the Ethics Commission of the University of Regensburg  and carried out in accordance with the approved guidelines of the Helsinki Declaration of 1975. A written informed consent was obtained from all study participants. Participation in this study was voluntary.After fulfilling the inclusion criteria, 89 patients were included, of whom 86 completed the study. Three patients had to be excluded due to technical problems, so they were not able to complete the questionnaire. From the remaining 86 patients, 40 were female and 46 males. Table .Table 1IThe algorithm of the app-based tool was developed in cooperation with members of Digital Health, medical doctors and psychologists. The idea for the tool algorithm is an algorithm that reflects the spinal surgeons´ way of thinking while he is taking the anamneses. First the algorithm was written down as a big decision tree. Then an app-based question tool was taken, and the questions were used within this frame setting to facilitate the evaluation. Thus, the algorithm and not the tool itself was subject of investigation.For safety reasons the typical red flag questions have to be answered all with “no”, otherwise the patient is sent directly to an emergency room. Then the patient chooses the area of pain .After that two to five dichotomic questions have to be answered with yes or no. These “decision” questions lead to the most likely diagnosis. This diagnosis is then reassured by a block of questions, which are sensitive for the supposed diagnosis. If more than 65% of the answers are “yes”, the diagnosis is confirmed. If not, the second most likely diagnosis is evaluated, by again a block of sensitive questions.If these are answered with “yes” in more than 65%, this diagnosis is taken, if not the patient it advised to go to see a doctor because a diagnosis cannot be found for certain (“no diagnosis”). See in Table The study was conducted in the Department of Orthopaedics of a University Medical Centre. All patients were seen by one of two spinal surgeons. Each examination took between 10 and 20 min. The app-based form was filled either before the appointment or directly before the consultation while waiting by the patient itself within a maximum of 5 min. The order was chosen by chance for a smooth integration in the daily clinical routine. There were two experienced consultant spine surgeons of the same experience working together for 10 years, which means that their thinking and decisions are comparable. They were blinded in that way, that they did not have any knowledge of the result of the tool. Thus, both procedures  were treated independently.After a first pilot study of 20 patients, the technical setting was improved using a better tablet. Some mistakes in linking the questions within the algorithm were fixed and the present study started.To calculate the number of necessary cases, the effect size was taken from our former study : With anV was used. All diagnoses were described in the result section. Furthermore, the combination between the medical and the computerized diagnoses were presented for every single diagnosis. A possible difference in the frequency was statistically investigated with the Chi-square test.The scored diagnoses were given by the spinal surgeons manually and by the tool as saved data. At first, the correlation between the diagnoses of the tool and the medical diagnosis were calculated. Because data were nominal scaled, and both variables have more than two characteristics, Cramers “Overestimation” means, that the tool´s diagnosis is more severe than the spinal surgeon´s diagnosis. E.g., the tool says herniated disc and the spinal surgeon says unspecific low back pain. The diagnoses facet joint arthritis, low back pain and Iliosacral joint block were regarded as equal as there is nearly the same first line conservative treatment.Relation between the tool and the diagnosis of the spinal surgeon:Table V = 0.711, p < 0.001, which can be taken as a strong relationship. This relation holds true, if the data were calculated separately for women, Cramer’s V = 0.720, p < 0.001 and men, Cramer’s V = 0.780, p < 0.001.Statistically, a significant relation between the tool and the diagnosis of the medical doctor could be carved out, Cramer’s χ2  = 10.47, p < 0.001).In 67.4% of the cases the diagnosis between the medical doctors and the DSS were concordant, in 32.6% they were discordant. The difference of the frequencies was statistically significant, χ2  = 77.74, p < 0.001); however, the difference of the frequencies between the categories “overestimation” and “underestimation” was not significant, χ2  = 2.58, p = 0.108).Analysing the over- and underestimation  the results showed that in 77.9% of the cases the diagnoses were concordant, in 15.1% they were overestimated, and in 7% they were underestimated by the DSS. The frequencies of the categories were statistically significant, The hypothesis that there is a correlation between the diagnoses of the spinal surgeons and the clinical decision support tool holds true. In comparison to former studies, the correlational effects are strong.Since ages symptom checkers are part of scientific work with the aim to unify and to simplify clinical diagnosis finding or to support patients identifying their problems themselves , 20. In Despite all these efforts only few studies were published in the field of back pain in the last years. In the present study 67.4% of the diagnoses between the medical doctors and the DSS were concordant, analysing the over- and underestimation the results even showed that 77.9% of the diagnoses were concordant.That means that e.g., pain because facet joint arthritis or low back pain was counted equally. Only 7% of the diagnoses were underestimated by the patients. But none of them was an urgent case. E.g., the tool recognized low back pain and the spinal surgeons diagnosed a spondylolisthesis without surgical indication.In comparison to other studies the concordance is really strong. In 2015 Semigran et al. evaluated 23 symptom checkers for self-diagnoses and triage . For thiFurther aim of this should not be to replace the medical doctor, but to help patients to have an initial assessment of their symptoms, decision making in outpatient centres or patient telephone hotline. In addition, it could help to triage in emergency rooms. The assessment only takes about 5 min. So, the tool can be used in waiting rooms as stand-alone tablet or on telephone hotlines by medical staff.Due to the different treatment methods and individual decisions, treatment recommendations were deliberately avoided when developing this tool. However, diagnosis-specific physiotherapy exercises are recommended to patients.In our former study, it is noticeable that there was a minor number of psychiatric diagnoses, a result which was not in line with the literature because depression and anxiety is related to back pain as well as avoidance behaviour , 17, 24.Despite the growing digitalization in all fields, this study is the first for 2 years to evaluate a specific kind of symptom checker for back pain.There are some limitations to the study. Only spinal surgeons who work at the same hospital were included for the clinical examination, which means that most patients have had some treatment before. Next, outpatient centres should be included, as there is usually the first contact to the patient and the doctors are general practitioners and not spine surgeons. Another limitation is that psychiatric diagnoses are not evaluated.This study showed strong correlation between the diagnoses by spinal surgeons and the clinical decision support system in back pain patients. In a next step it should be evaluated, if the tool can help to reduce the time that passes before a successful treatment is achieved for those patients.


Transforaminal epidural steroid injection (TFESI) or dorsal root ganglion pulsed radiofrequency (PRF) are alternative treatments for lumbosacral radicular pain (LSRP). This study aimed to investigate the clinical efficacy of TFESI combined with dorsal root ganglion PRF using bipolar technology to treat LSRP in patients with pain duration ≥ 2 years.This prospective single-armed cohort study included 20 patients with LSRP duration ≥ 2 years, who underwent treatment of TFESI combined with bipolar PRF. The primary outcomes included numerical rating scale (NRS) and successful treatment rate (pain relief ≥50%). The secondary outcomes included Oswestry Disability Index (ODI), patient satisfaction using the modified MacNab criteria, severe complications, hospital stay and total costs. The final follow-up was 6 months postoperatively.P < 0.001), while the mean ODI score significantly decreased from 43.5 ± 2.5 to 22.5 ± 4.3 at 2 weeks postoperatively, to 20.0 ± 3.5 at 3 months postoperatively, and to 19.5 ± 3.6 at 6 months postoperatively . The excellent and good patient satisfaction at 6 months postoperatively was 85%. No severe complications were observed in this cohort. The average hospital stay and total costs were 3.0 ± 0.5 days and 3.36 ± 0.77 thousand dollars, respectively.The successful treatment rate and average pain relief at 6 months postoperatively were 80% and 73.0% ± 17.5%, respectively. The successful treatment rates in patients with and without prior intervention history at 6 months postoperatively were 77.8% and 81.8%, respectively. The mean NRS score significantly decreased from 6.5 ± 0.8 to 1.1 ± 0.7 at 2 weeks postoperatively, to 1.3 ± 0.7 at 3 months postoperatively, and to 1.7 ± 1.0 at 6 months postoperatively (all The treatment of TFESI combined with PRF using bipolar technology might be an alternative option to treat chronic LSRP in patients with pain duration ≥ 2 years after a failure of conservative treatments, with a favorable 6-month efficacy and inexpensive total costs. However, long-term outcomes and superiority of bipolar procedure over monopolar procedure in patients with longer pain duration should be further investigated in future studies. Lumbar disc herniation (LDH) is a common degenerative spinal disease and it causes low back pain and lumbosacral radicular pain (LSRP). The incidence rate of LDH is 10–20%  and it bTransforaminal epidural steroid injection (TFESI) is one of the most common interventional options for the treatment of LDH  and sevePrevious studies have demonstrated that single-level bipolar pulsed radiofrequency treatment was an effective procedure for treating chronic refractory lumbosacral pain , which iThis was a prospective single-armed cohort study (sample size = 20), which had a similar study design to a previous retrospective study with a sample size of 23 published in Pain Physician . All parAll patients were continuously enrolled according to the patient selection criteria. The inclusion criteria were as following: (i) age > 18 years old; (ii) diagnosis of mild to moderate LDH  with unilateral chronic LSRP and numerical rating scale (NRS) scores ≥4; (iii) pain duration ≥ 2 years; (iv) a failure of conservative treatment including medication such as NSAIDs drugs, pregabalin, vitamin B12, neurotropin etc., physical therapy, best rest and so on; (v) unwilling to have open surgery or able to tolerate the interventional surgery; (vi) willing to have the interventional surgery.The exclusion criteria were as following: (i) failed back surgery syndrome; (ii) lumbar spinal stenosis ; (iii) Medical Research Council grade ≤ 3 in lower extremity muscle strength, and incontinence of urine and feces. (iv) spinal diseases such as spondylolisthesis, spinal scoliosis, and facet joint syndrome.Lumbosacral radicular pain pain intensity using a NRS was the primary outcome. NRS allows the subject to choose one number between 0 and 10 that best represents their current level of pain (0 being no pain and 10 being the most intense pain ever experienced by the subject). Pain reduction percentage was defined as the following: (preoperative NRS – postoperative NRS)/preoperative NRS *100%. Pain relief by at least 50% was defined as treatment success.The Oswestry Disability Index (ODI) was applied to evaluate the disability, and the modified MacNab criteria were used to measure postoperative patient satisfaction. The levels of patient satisfaction were determined as the following: excellent , good , fair , or poor . ODI scores of ≥50% reduction were calculated.Severe complications including nerve injury, infection, hematoma, and reoperation  were recorded during the operation or after the surgery.General demographic data were collected through the electronic medical record. Pain duration in patients with prior intervention treatments was collected from the time of new onset of LSRP after the last surgery to the bipolar surgery. Postoperative data were followed up through telephone questionaries or in the outpatient setting during follow-ups. Outcome variables were assessed at 2 weeks, 3 months, and 6 months postoperatively, by an independent researcher who was not in charge of the clinical treatments of the patients.Patients were in a prone position. Under the guidance of anteroposterior and lateral C-arm fluoroscopy, the bipolar procedure of TFESI combined with PRF was performed. A pillow was placed under the abdomen during the procedure and patients were kept awake to answer questions about sensory stimulation. A total of 5 mL of 1% lidocaine was injected into the skin entry as local anesthesia.To perform the PRF procedure using bipolar technology, two 22-gauge cannulas were applied to place adjacent to the dorsal root ganglion . AfterwaTo perform TFESI after PRF treatment, a mixture of 0.2% ropivacaine 2 mL and betamethasone about 1 mg were injected via each needle. An amount of betamethasone no greater than 7 mg was administered when multiple segments were targeted in one surgery.The initial operation levels were roughly determined by pain areas in lower limbs and levels of LDH in MRI and CT imaging. Then the sensory test during the operation further confirmed whether the level was or not responsible for the pain. Finally, contrast medium spreading patterns were used to identify the right position of the needle tips. The next anteroposterior and lateral C-arm fluoroscopy were taken when all needles were placed or adjusted according to the last C-arm fluoroscopy.All patients were discharged with 2-week medications, such as anti-inflammatory drugs (mainly NSAIDs), neurotrophic drugs, or neuromodulatory agents. The decisions of dose reduction, increase and withdrawal were made according to patients’ recovery during follow-ups. Patients were routinely inquired to come to outpatient clinic at 2 weeks, 3 months, 6 months postoperatively and the frequency increased if diseases worsened.t-test was used to compare the changes of NRS and ODI scores between preoperation and postoperation or among different postoperative follow-up points, and chi-square test or Fisher’s exact test was used to analyze excellent and good satisfaction rates among different postoperative follow-up points. A p-value of no more than 0.05 was considered significant. All analyses were performed in R software (version 3.6.4). R software and Adobe Illustrator CC were used for figure preparation.The mean ± standard deviation or median (interquartile range) was used to present quantitative data, as appropriate, and frequency (percentage) was applied to describe categorical data. Paired student’s A total of 1,272 patients with low back pain or LSRP underwent minimally invasive intervention treatments from December 2020 to October 2021, 546 patients received endoscopic spinal surgeries and 726 patients underwent interventional treatments including dorsal root ganglion PRF, TFESI, disc decompression with percutaneous coblation nucleoplasty, medial branch radiofrequency ablation, or their combined treatments. Among 726 patients with interventional treatments, 20 patients  with unilateral LSRP and LDH underwent bipolar procedures of TFESI combined with PRF. Fourteen patients  had the right sites of TFESI-PRF procedures. L4, L5, and S1 spinal nerve levels accounted for 75% of operation sites (15/20). Nine patients had a surgery history of nerve root blocks under the guidance of ultrasound (7/9) and TFESI combined with monopolar PRF (2/9). The average age of patients was 55.5 ± 4.6 years. The median and interquartile range of pain duration was 4 years (ranging from 2 to 9 years). Patients presented moderate to severe radicular pain (NRS ≥ 4) at admission, with a mean baseline NRS score of 6.5 ± 0.8. The average operation time was 46.5 ± 16.8 min. Most patients gradually stop pain medications at 2 weeks – 3 months postoperatively. The general demographics are presented in P < 0.001). There was an increasing trend of NRS scores at postoperative follow-up points from 2 weeks to 3 months postoperatively (P = 0.423) or from 3 months to 6 months postoperatively (P = 0.198) or from 2 weeks to 6 months postoperatively (P = 0.06), as displayed in The successful treatment rate at 6 months postoperatively in this population was 80%. Two patients had NRS scores ≥ 4 at 6 months postoperatively, whose duration time of symptoms was 8 and 9 years, respectively. The average pain reduction percentage at 6 months postoperatively in these 20 patients was 73.0% ± 17.5%, and all patients achieved pain relief of more than 30% at both 2 weeks, 3 months, and 6 months after the operation. The successful treatment rates in patients with and without prior intervention history at 6 months postoperatively were 77.8 and 81.8%, respectively. Among 7 patients with prior history of nerve root blocks, two of them had pain reduction <50% at 6 months postoperatively. Two patients with prior TFESI combined with monopolar PRF both had pain relief ≥50% at 6 months postoperatively. Among 11 patients with no surgery history, two of them (18.2%) had pain reduction <50% at 6 months postoperatively. The NRS scores at the three postoperative follow-up time points were lower than those at baseline , 20.0 ± 3.5 at 3 months postoperatively (P < 0.001), and 19.5 ± 3.6 at 6 months postoperatively (P < 0.001), as displayed in P = 0.172) or from 3 months to 6 months postoperatively (P = 0.753) or from 2 weeks to 6 months postoperatively (P = 0.111). Among 20 patients, 15 patients (75%) had ≥ 50% reduction in ODI at 6 months postoperatively.The mean ODI score decreased from 43.5 ± 2.5 preoperatively to 22.5 ± 4.3 at 2 weeks postoperatively (P > 0.05), as displayed in The excellent and good patient satisfaction rate at 6 months postoperatively was 85%. Excellent and good patient satisfaction was achieved in 100% of patients at 2 weeks postoperatively and 90% of patients at 3 months postoperatively. There were no significant differences among 2-week, 3-month, and 6-month postoperative excellent and good satisfaction rates . No severe complications were observed in this study.In this study, we used bipolar treatments of TFESI combined with dorsal root ganglion PRF to treat LSRP in patients with pain duration ≥ 2 years. By applications of multilevel treatments, combined treatments of TFESI and PRF, and bipolar PRF procedures, which were highlights of this study, favorable 6-month outcomes were achieved in the patients whose pain duration was ≥ 2 years, with inexpensive hospital total costs and without severe complications. However, the superiority of bipolar procedure over the monopolar procedure in patients with longer pain duration should be further investigated in future studies.Previous studies have demonstrated that bipolar PRF treatment was an effective procedure for treating chronic refractory lumbosacral or cervical radicular pain, particularly in patients whose pain is refractory to TFESI or monopolar PRF . In addiThe procedure of multilevel PRF was determined by comprehensive consideration including symptom areas, possible nerve-affected nerve root levels based on findings in MRI and CT, and intra-operative sensory test results. Although there is a cephalad and caudad flow possibility of injection solution after a single-level TFESI , PRF treThe indications for intervention treatments and patient selections were the key points for a successful treatment. If the LSRP was caused by compression of huge herniated nucleus pulposus, severe stenosis of the spinal canal and intervertebral foramen, spondylolisthesis, scoliosis, etc., decompression surgery (open surgery or endoscopic spine surgery) was indicated in these conditions. While TFESI or PRF would be indicated for predominant neuroinflammation , nerve eWith the strategies including preoperative patient selection, intra-operative accurate position confirmation of the needle tip, PRF treatment of multilevel dorsal root ganglions, and administration of bipolar dorsal root ganglion PRF, the average pain reduction percentage at 6 months postoperatively was 73.0% ± 17.5% and the successful treatment rate at 6 months postoperatively was as high as 80%. However, the comparison in long-term outcomes of multilevel bipolar TFESI-PRF to TFESI alone or PRF alone or single-level TFESI-PRF is still needed to be investigated in future studies.n = 20) was close to that in Lee’s study (n = 23) (n = 19)   and Chan(n = 19) , the samThe treatment of TFESI combined with PRF using bipolar technology might be an alternative option to treat LSRP in patients with pain duration ≥ 2 years after a failure of conservative treatments, even TFESI alone or PRF alone, with a favorable 6-month efficacy and inexpensive hospital total costs. However, long-term outcomes and superiority of bipolar procedure over monopolar procedure in patients with longer pain duration should be further investigated in future studies.The original contributions presented in this study are included in the article/supplementary material, further inquiries can be directed to the corresponding author/s.The studies involving human participants were reviewed and approved by the Ethics board of the Peking University Third Hospital (No. M2018092). The patients/participants provided their written informed consent to participate in this study.SL and XL: conceptualization, investigation, supervision, project administration, and funding acquisition. SL, XL, QL, and DY: methodology. QL, DY, and ZZ: formal analysis. QL and DY: data curation. QL: writing – original draft preparation. All authors writing – review and editing. All authors have read and agreed to the published version of the manuscript.