Background and Objectives: Chronic neck pain and low back pain are common conditions in high-income countries leading to social and medical problems such as invalidity and decreased quality of life. The aim of this study was to investigate the effect of supra-threshold electrotherapy on pain level, subjective feeling of disability, and spinal mobility in patients with chronic pain in the spinal cord. Materials and Methods: 11 men and 24 women with a mean age of 49 years were randomly divided into three groups: group 1, “therapy”: supra-threshold electrotherapy was applied on the whole back after electrical calibration; group 2, “control”: electrical calibration without successive electrotherapy; group 3, “control of control”: no stimulation. Sessions were performed once a week and six times in total, each lasting 30 min. The numeric pain rating scale (NRS), cervical and lumbar range of motion (ROM), as well as disability in daily live were investigated before and after the sessions using questionnaires ). Results: Spinal mobility improved significantly in the lumbar anteflexion  and retroflexion  in the group receiving electrotherapy. Pain levels measured by the NRS and disability-questionnaire scores did not differ significantly before and after treatment in any of the groups. Conclusions: Our data indicate that regular supra-threshold electrotherapy for six times has a positive effect on lumbar flexibility in chronic neck pain and low back pain patients, whereas pain sensation or subjective feeling of disability remained unchanged. Chronic neck pain and low back pain are common causes of invalidity and decrease in quality of life in high-income countries. However, the effectiveness of pain medication is limited . TherefoElectrotherapy, especially transcutaneous electrotherapy (TENS), has been an inexpensive, easily applied and widely used tool in different painful conditions for several decades. The reduction in pain by electrotherapy is suggested to be due to several mechanisms. One of them is the gate-control-theory by Melzack and Wall, which proposes the modulation of afferent nociceptive patterns in the superficial dorsal horn of the spinal cord, i.e., the inhibition of small afferent nociceptive fibres by large afferent fibres, and consequently, activation of inhibitory interneurons, thus leading to less nociceptive input to neurons projecting to the brain . Other sHowever, up to now there is scarce evidence for the clinical efficacy of TENS therapy in neck pain  or low bTherefore, the aim of the present study is to investigate the effect of regular, supra-threshold electrotherapy in pain sensation and in cervical and lumbar range of motion, as well as in the subjective feeling of disability in daily life. Thereby, a mat covering the whole spinal cord was used for current application, aiming a deeper tissue penetration and an increased effectiveness compared with conventionally used TENS.This randomized controlled, double-blind pilot study was performed at the Medical University of Vienna, Department of Special Anesthesia and Pain Therapy. ClinicalTrials.gov, accessed on 5 January 2023 (INS-621000-0687-002).The study was approved by the local ethics committee of the Medical University of Vienna  and registered with the Austrian Federal Office for Safety in Health Care BASG (INS-621000-0687), as well as with A total of 54 male and female patients aged 18 years or over with chronic neck pain or low back pain were enrolled in the study. The inclusion criteria were a minimum numeric rating scale equal to or greater than five, and pain duration of more than three months. The oral pain medication had to be stable at least four weeks prior to the first investigation. No additional pain therapies  were allowed parallel to the study. Such pain therapies had to be discontinued at least four weeks before the study onset. Patients with experience in TENS were excluded. Other exclusion criteria were pregnancy, epilepsy, cardiac arrhythmia, cardiac surgery including implanted pacemaker or defibrillator, previous surgery in the spinal cord, infectious diseases of the spinal cord, malignant tumors with or without secondary blastomas in the spinal cord, severe radicular pain with acute paralysis in the extremities, or an ongoing pension application. ®; cervical range of motion CROM basic spinal assessment device; ProHealthcareProducts.com, accessed on 5 January 2023, 770 East Main Street, #201 Lehi, UT 84043, USA) and with the modified Schober method (assessment of anteflexion and retroflexion 10 cm above and 5 cm below the anterior superior iliac spine). Subjective feeling of disability in daily life was assessed with questionnaires . Written informed consent was obtained from all patients included in the study. Before the initiation of the electrotherapy sessions and recording of demographic information including age, gender, weight, height and body mass index, laboratory parameters and an X-ray of the spinal cord were examined to exclude any signs of new onset malignancies or infections in the spinal cord. Before and after the therapy sessions, actual pain in rest and under activity, as well as the maximum and minimum pain in the last four weeks were assessed using the numeric rating scale (NRS) for the cervical, dorsal, and lumbar region, respectively. The quality of pain was evaluated using the Short-form Mc Gill Pain Questionnaire (SF-MPQ). The PainDETECT test was used to screen for radicular involvement. Range of motion (ROM) was assessed using the Cervical Range-of-Motion Instrument  that was warmed to 25 °C , the device calibration was performed without any further subsequent electrical stimulation. The third group (“control of control”) lay on the mat without the application of any electrical stimulation.Computer-based randomization stratified by age, gender and pain location (neck pain vs. dorsolumbar pain) was performed. All patients, as well as the physician performing the physical examination, were blinded and randomly divided into three groups. The first group of patients (“therapy”) received a supra-threshold electrotherapy with alternating current application, consisting of high-frequency stimulation at 100 Hz and low-frequency stimulation at 2 Hz, which is used in daily clinics  and been® and the modified-Schober method.The primary endpoint of the study was the pain sensation (NRS) of the chronic neck pain and low back pain after electrotherapy compared with the control groups. The secondary endpoints were QoL, assessed by the Neck Disability Index and the Rolland Morris Questionnaire, as well as the ROM measured with CROMt-test or the One-way ANOVA for normal distribution, and Wilcoxon Signed Rank test or Kruskal–Wallis ANOVA on ranks, if the normality test (Shapiro–Wilk test) failed. All comparisons in this pilot study were regarded to be of exploratory nature and no adjustment for multiple testing was performed. p < 0.05 was considered as statistically significant. Statistical analysis was performed using Sigma Plot 12.0 . The intra-individual analysis , as well as inter-individual analysis  were performed using the paired A total of 54 patients with chronic neck pain or low back pain were included in the study. Thereof, 35 patients  were finally analyzed. Among these patients, seven patients had cervical pain only, 14 patients had low back pain solely, and 14 patients had both. All patients primarily exhibited local back pain, without or with little radicular pain. n = 9), control group (n = 7), and control of control (n = 5). The subset of 28 patients with chronic low back pain were further divided into the therapy group (n = 10), control group (n = 10), and control of control (n = 8)  were divided into the electrotherapy group (= 8) see . For the demographic description of the patients, see Among the 35 patients, 12 (34.29%) did not take any pain medication. Of the remaining 23 patients, 22 took non-opioid medication regularly, 6 of whom took a combination with opioids and 8 of whom took antidepressant medication. One patient took antidepressants only. Depression was previously diagnosed in 7 patients out of 35 . No increase or decrease in the intake of rescue pain medication was reported by any of the patients investigated during or after the weekly sessions.The average, minimum and maximum NRS of cervical and low back pain, at rest and under activity showed no significant changes before and after the therapy sessions in any of the groups. (The mean and standard deviation of baseline (pre) and post session (post) values are stated below.)p = 0.46; control: pre 4.7 ± 1.5, post 4 ± 1.9, p = 0.41; control of control: pre 5.6 ± 2.41, post 5.4 ± 1.95, p = 0.8;Average NRS: therapy: pre 6.2 ± 2.3, post 5.3 ± 2.45, p = 0.72; control: pre 1.71 ± 1.7, post 2 ± 1.53, p = 0.63; control of control: pre 2.6 ± 2.97, post 1.4 ± 2.19, p = 0.32;Minimum NRS: therapy: pre 3.33 ± 3.35, post 2.89 ± 1.9, p = 0.24; control: pre 6.71 ± 0.76, post 6.14 ± 1.68, p = 0.44; control of control: pre 7.2 ± SD 1.48, post 7.6 ± 1.82, p = 0.76;Maximum NRS: therapy: pre 8.22 ± 1.2, post 7.56 ± 1.67, p = 0.58; control: pre 4.14 ± SD 2.41, post 2.43 ± 1.27, p = 0.04; control of control: pre 4.2 ± 3.9, post 4.2 ± 3.35, p = 1;NRS at rest: therapy: pre 5.11 ± 2.85, post 4.44 ± 2.52, p = 0.46; control: pre 5.43 ± 1.99, post 3 ± 2, p = 0.04; control of control: pre 4.6 ± 2.07, post 5.4 ± 1.95, p = 0.18.NRS under activity: therapy: pre 5.4 ± 2.55, post 4.67 ± 2.65, p = 0.17; control: pre 4.5 ± 0.97, post 4.7 ± 2.91, p = 0.1; control of control: pre 4.88 ± 2.36, post 4 ± 2.56, p = 0.06;Average NRS: therapy: pre 5.5 ± 1.58, post 6.2 ± 2.15, p = 0.19; control: pre 1.5 ± 1.65, post 2.3 ± 2.31, p = 0.29; control of control: pre 2.38 ± 2, post 2.13 ± 2.23, p = 1;Minimum NRS: therapy: pre 1.9 ± 2.02, post 3 ± 2.31, p = 0.25; control: pre 6.6 ± 1.51, post 4.7 ± 2.91, p = 0.12; control of control: pre 7.75 ± 1.83, post 6.63 ± 2.92, p = 0.11;Maximum NRS: therapy: pre 8.5 ± 1.27, post 8.1 ± 1.52, p = 0.85; control: pre 3.7 ± 2.31, post 3 ± 3.02, p = 0.47; control of control: pre 3.25 ± 2.66, post 3.38 ± 4.14, p = 0.91;NRS at rest: therapy: pre 3.8 ± 2.44, post 3.9 ± 3.14, p = 0.59; control: pre 4.1 ± 2.73, post 3.44 ± 2.74, p = 0.59; control of control: pre 5.5 ± 3.63, post 4 ± 3.92, p = 0.33 . The mean and standard deviation of the baseline (pre) and post session (post) of all the groups, as well as the 95% confidence intervals (CI) are stated, as follows:Next, a comparison of the total NRS at rest, under physical activity, minimal, maximal, as well as average NRS between the three groups was performed. Thereby, the respective sums of the NRS of the cervical, dorsal, and lumbar regions were calculated. ANCOVA using the pre-value of the groups as a covariant did not reveal any significant differences between the means post intervention (n = 13): 13.15 ± 6.04; control (n = 13): 7.31 ± 3.82;Average NRS: Pre: therapy (n = 9): 9.22 ± 4.82. Post: therapy (n = 13): 13.2 ± 5.7; control of control (n = 13): 6.8 ± 4.8; control of control (n = 9): 9.1 ± 6.6. control (Comparison therapy vs. control: CI of the mean difference 2.02 (−1.54–5.58),p = 0.25.Comparison therapy vs. control of control: CI of the mean difference 0.52 (−2.71–3.74),p = 0.74.n = 13): 2.62 ± 3.48; control of control (n = 9): 4.44 ± 4.61. Post: therapy (n = 13): 5.5 ± 4.4; control (n = 13): 3.5 ± 3.3; control of control (n = 9): 2.8 ± 3.6.Minimum NRS: Pre therapy (n = 13): 5.0 ± 5.0; control (p = 0.67.Comparison therapy vs. control: CI of the mean difference 0.52 (−1.94–2.97), Comparison therapy vs. control of control: CI of the mean difference 2.43 (−0.33–5.19), p = 0.08.n = 13): 18.62 ± 6.29; control (n = 13): 10.69 ± 4.13; control of control (n= 9): 14.56 ± 6.64. Post: therapy (n = 13): 18.8 ± 5.4; control (n = 13): 9.8 ± 5.4; Maximum NRS: Pre: therapy (n = 9): 13.7 ± 6.4.control of control (p = 0.055.Comparison therapy vs. control: CI of the mean difference 4.57 (−0.1–9.25), Comparison therapy vs. control of control: CI of the mean difference 2.9 (−1.57–7.38),p = 0.19.n = 13): 6.15 ± 5.03; control of control (n = 9): 6.67 ± 5.72. Post: therapy (n = 13): 7.7 ± 5.5; control (n = 13): 4.8 ± 3.6; NRS at rest: Pre: therapy (n = 13): 8.77 ± 5.97; control (control of control (n = 9): 7.0 ± 7.2.p = 0.32.Comparison therapy vs. control: CI of the mean difference 1.38 (−1.46–4.23), Comparison therapy vs. control of control: CI of the mean difference −1.01 (−4.81–2.79),p = 0.58.n = 13): NRS under physical activity: Pre: therapy (n = 13): 12.54 ± 5.77; control (n = 9): 9.44 ± 5.88; Post: therapy (n = 13): 11.6 ± 6.0; 7.31 ± 5.54; control of control (n = 12): 5.6 ± 4.5; control of control (n = 8): 9.6 ± 7.4.control (p = 0.15.Comparison therapy vs. control: CI of the mean difference 3.12 (−1.27–7.5), Comparison therapy vs. control of control: CI of the mean difference −0.96 (−6.44–4.51),p = 0.72.No improvement in daily living was shown either in the Neck Disability Index or in the Rolland Morris Questionnaire. Likewise, there were no significant differences in the total scores of the SF-MPQ see .Regarding the cervical range of motion, in all groups, there were no significant changes in any planes assessed before and after the electrical stimulation see .p = 0.003; control: pre 21 ± 1.65, post 20.63 ± 1.35, p = 0.25; control of control: pre 21.84 ± 1.83, post 21.43 ± 2.42, p = 0.39) as well as in retroflexion . Among the 13 patients that were incorrect, 8 patients thought they had received sham therapy, although regular electrotherapy was applied. The remaining five patients that wrongly believed they had received verum therapy were all assigned to the group “control of control”, where no electrical stimulation was applied at all.To assess the effectiveness of blinding, patients were asked at the end of the study whether they had received true or sham therapy. Among 25 subjects, 12 (48%) were correct . Indefinite answers were not accepted so that patients had to guess if they were uncertain. The proportion of patients who answered correctly was 48%. Considering that the probability of guessing correctly by chance is about 33%, and that in the case of unblinding or failed blinding, the percentage of correct answers would be 100%, our result seems, at first sight, not that unsuccessful. However, this consideration is statistically incorrect, and a calculation such as the blinding index proposed by James and colleagues  or Bang n = 37 was calculated. Taking a dropout rate of 30% in consideration, the optimal sample size was increased to n = 50 for the intervention group and control group, respectively. The patient number of the control of control group was set to 10 because no physiological changes were expected in these patients who did not receive any electrical current. However, because of difficulties in patient recruitment (there were hardly any chronic pain patients who had not experienced TENS previously) and due to lack of time and resources, there were finally fewer patients included in the study. This led to more varied distribution of patients than initially planned; however, there were no statistically significant differences in any of the baseline values between the groups.It is obvious that the number of the participants is small, and a greater number of patients would improve the statistical power. Initially, sample size was calculated based on a previous TENS study performed in patients with chronic low back pain, where a difference of NRS of 1 between the groups (primary end point) was used. A power of 80% and standard deviation of 1.5 were set based on the study of Pop et al. . A samplFurthermore, insufficient blinding or biasing due to dropouts might falsely produce a negative effect of electrotherapy. Most patients (14/19) who dropped out did so right after the baseline investigation before randomization was performed and the weekly sessions started. The remaining five patients belonged to the group receiving supra-threshold electrotherapy and quit after the performance of one to four therapy sessions  No adverse events were observed in these patients. Since the patients were not obliged to state a reason for the discontinuation, this could not be further analyzed. In two of the five patients, depression was diagnosed, and one patient had a diagnosis of depression and anxiety disorder before the enrolment. NRS, QoL and ROM were investigated at the very beginning of the study before randomization was performed, and at the end of the study after the completion of the six sessions of intervention; therefore, we cannot determine whether there were any changes in the pain level between these times. A possible reason for discontinuation may have been a perceived inefficacy of the therapy and a mismatch with the patients’ therapeutic beliefs and expectations.Finally, another possible explanation for the unchanged pain sensation could be that, according to the bio–psycho–social model of pain, the existence of psychologic or socioeconomic factors that do not change easily, such as anxiety, maladaptive behavior, stressful circumstances, poverty, or biological factors, such as remodeling in the central nervous system, tend to result in chronic pain states . Since c® can also be used as a part of physiotherapy to strengthen the back muscles, e.g., in frailty due to chronic critical illness or in postoperative settings. Its easy handling with an attached remote controller allows patients to manage their pain therapy concerning the optimal timing, frequency, and stimulus intensity themselves. In combination with optimal dietary nutrition, it might be an effective and time-efficient tool in rehabilitation programs, which is a topic for future studies. The reported values for mean and standard deviations may be used in the sample size planning of future studies.In this study, the use of mid-frequency electrotherapy was restricted to chronic neck pain and low back pain. However, StimawellThe current pilot study shows that regular mid-frequency electrotherapy applied in patients with chronic neck pain or non-specific low back pain improved the range of motion of the lower spinal cord significantly, whereas pain sensation remained unchanged. Although a significant improvement of pain levels could not be revealed in this trial, the electrotherapy mat remains a feasible therapeutic option as functional improvement also constitutes an important therapeutic goal in chronic low back pain.


Panic attacks(PA) or episodic paroxysmal anxiety are attacks of severe anxiety (panic) or fear , accompanied by a rapid heartbeat and a feeling of “suffocation” , “lack of air.” Sometimes there are additional symptoms such as increased blood pressure, a feeling of “internal trembling”, trembling in the limbs, a feeling of “hot flashes” of heat or cold, numbness of the extremities, increased sweating, a feeling of “unstability” or dizziness, nausea, derealization or depersonalization.It was revealed that many patients with cervical and spinal pain suffer from PA. Psychotherapy and traditional psychopharmacology treatment often not effective. The goal of our study was analysis of radical anti-oxidative therapy for the PA patients in addition to traditional to traditional psychoparmacology and psychotherapy techniques.12 patients with cervical and 31 with lumbar pain experienced panic attacks during outbreaks of panic attacks. 6 cervical pain patient and 17 patients with lumbar pain were treated by antipsychotic medications also by cognitive behavioral therapy, hypno-suggestive therapy and autogenic training. Other patients also receive hyperbaric oxidation therapy (HBO) in addition to psychopharmacology and psychotherapy.It was revealed that patients with PA comorbid with vertebral pathology had much better effects in terms of evading of psychopathologic outcomes. PA became much more rarely and finally disappeared at all. The anti-oxidative treatment was also very beneficial for neurologic symptoms cause by vertebral pain.Anti-oxidative therapy showed very marked effect. In this regard, new anti-oxidative treatment seems to be promisable for management of such conditions.None Declared


Background and Objectives: With the aging population, the incidence of degenerative lumbar spinal stenosis (LSS) is increasing. Sarcopenia is an age-related muscular decrease. Although epidural balloon neuroplasty is effective in patients with LSS refractory to conventional treatments, its effect has not been assessed in patients with sarcopenia. Therefore, this study evaluated the effect of epidural balloon neuroplasty in patients with LSS and sarcopenia. Materials and Methods: This retrospective study reviewed the following details from the electronic medical records: patient characteristics, including sex, age, body mass index, diabetes, hypertension, stenosis grading, pain duration, location, pain intensity, and medications. Back and leg pain intensity was evaluated before and after the procedure at one, three, and six months during the follow-up period. A generalized estimating equations model was used at six months follow-up. Patients were divided into sarcopenia and non-sarcopenia groups using the cross-sectional area of the psoas muscle at the level of L3 on magnetic resonance imaging. Results: A total of 477 patients were included . Age, sex, body mass index, and medication quantification scale III were statistically different between both groups. The generalized estimating equations analyses—with unadjusted and adjusted estimation—revealed a significantly reduced pain intensity after the procedure compared to the baseline in both groups. The difference in pain intensity between both groups was not statistically different. Conclusions: Percutaneous epidural balloon neuroplasty may be considered for patients with chronic lumbar LSS regardless of accompanying sarcopenia. The aging process is accompanied by changes in body composition, with loss of skeletal muscle and lean body mass, reduced bone mineral density, and increased fat mass. The European Working Group on Sarcopenia in Older People (EWGSOP) defined sarcopenia as a progressive and generalized loss of skeletal muscle mass and muscle strength or physical performance with advancing age . SarcopeSarcopenia is associated with a risk of adverse outcomes, such as physical disability, poor quality of life, and death ,4. RecenMost older adults experience low back pain, leg pain, and claudication associated with lumbar spinal stenosis (LSS) ,12,13,14Although sarcopenia is known to be associated with poor prognosis after lumbar spine surgeries ,22,23, oThis study was retrospectively conducted at our pain clinic. All data used in this study were itemized and filled out in the patients’ electronic medical records (EMR) when the patient visited the pain clinic. Our institutional review board  approved this retrospective study and waived the requirement for obtaining informed consent because only documented data were reviewed.We reviewed the data of all patients who had undergone PEBN from January 2014 to December 2018. The inclusion criteria were (1) patients aged ≥ 65 years with radicular leg pain and/or back pain; (2) patient’s symptoms have persisted for over three months; (3) lumbar central or foraminal stenosis (any grade) was diagnosed using magnetic resonance imaging (MRI); (4) conventional treatment, including typical epidural steroid injections, had failed. The exclusion criteria were as follows: (1) history of prior lumbar spine surgery before balloon neuroplasty, (2) patients without proper radiologic images (MRI), (3) those who had no available data in EMR, (4) patients lost to follow-up entirely after the procedure.The procedure started with meticulous sterile preparation to ensure aseptic conditions. The patient’s skin and soft tissues were carefully infiltrated with 1% lidocaine for local anesthesia. To access the epidural space, a specially designed 10-G guide needle was inserted through the sacral hiatus under intermittent fluoroscopy, taking care to prevent cutting or skiving of the catheter.To confirm the correct placement of the guide needle in the epidural space, approximately 8 mL of diluted contrast medium  was injected under fluoroscopy. The diluted contrast mixture consisted of approximately 4 mL of pure contrast medium, 4 mL of 1% lidocaine, and 1500 IU of hyaluronidase. The contrast flow was carefully observed to check for any filling defects, which could indicate potential complications such as intravascular placement of the needle or contrast. If any issues were identified, the needle was promptly repositioned to ensure accurate placement.®, JUVENUI, Seoul, Republic of Korea) was advanced through the guide needle to the site of the filling defect or the pathology site, as determined by MRI or symptomatology. Gentle mechanical adhesiolysis and decompression were then performed using the ZiNeu catheter at the designated target sites, which included the central ventral and dorsal epidural spaces, lateral recess area, and/or each intervertebral foramen.Once the epidurogram and target areas were appropriately identified, an epidural inflatable balloon catheter , and each ballooning process was limited to five seconds to minimize the risk of adverse effects. The degree of balloon inflation was adjusted based on the patient’s pain response; if moderate-to-severe pain was reported during balloon inflation, no further attempts were made due to safety concerns. It is important to note that the catheter remained deflated while being moved to avoid any potential complications.After adhesiolysis and decompression, 1 mL of pure contrast medium was injected to detect subarachnoid or intravascular filling and to ensure satisfactory filling of previous defects. Subsequently, 2 mL of 1% lidocaine combined with 5 mg of dexamethasone was injected at each target site to provide pain relief and reduce inflammation. At the conclusion of the procedure, a Perifix epidural catheter  was left in place at the main target site through the ZiNeu catheter lumen. The position of the Perifix catheter tip was confirmed, and the ZiNeu catheter was then carefully removed.In the recovery room, a test injection of 2 mL of lidocaine was administered via the Perifix catheter. After monitoring for 10–15 minutes to ensure there were no adverse reactions, another 4 mL of 10% hypertonic saline was injected via the Perifix catheter. The Perifix catheter was left in place for a two-day drug injection regimen.On the second day post-procedure, the Perifix catheter was removed after injecting the same drugs  following another test injection. All patients were discharged after confirming.Baseline characteristics, including age, sex, body mass index (BMI), hypertension, diabetes, pain duration, location, intensity, and medications, were retrieved from the EMR. The location, grade, and total number of LSS  were recorded from MRI images using a photo archiving and communication system .2/m2 [2/m2 for men and 414.5 mm2/m2 for women at the L3 level [The measurement of the cross-sectional muscle area of the psoas muscle was conducted using T2 weighted axial images of MRI at the L3 level, as outlined in a previous study . The fas2/m2 . SarcopeL3 level . This deThe primary outcomes of this study were assessed based on improved pain intensity in the back and leg, as measured using an 11-point numeric rating scale (NRS). In addition, the medication quantification scale III (MQS) was utilized to quantify analgesic changes, and these assessments were conducted at the baseline, as well as at one, three, and six months after the procedure . These ot-test or Mann–Whitney U test, as appropriate. We used Fisher’s exact tests or Pearson’s chi-square to analyze the categorical variables between the two groups.Continuous variables were shown as the median and interquartile range or mean and standard deviation if skewed. Frequencies and percentages were used to present categorical variables. To compare the baseline differences between the two groups, we compared continuous variables using the Student’s p < 0.05 was statistically significant.We used a generalized estimating equations (GEE) model to replace missing data throughout the follow-up period. Stata version 13.1  and IBM SPSS Statistics for Windows, version 22.0 , were conducted for data manipulation and statistical analysis. A value of During the study period, 1218 patients who underwent PEBN were enrolled in the entire cohort; 741 were excluded based on the study criteria. Among the 741 excluded patients, 453 were younger than 65 years, 41 had undergone lumbar spine surgery before PEBN, 28 had no or poor radiologic images, and 219 had non-available clinical data. Eventually, this study included 477 patients who were divided into the sarcopenia  and non-sarcopenia  groups .p = 0.031). The non-sarcopenia group had a significantly higher proportion of male patients  and a significantly higher BMI (25.8 (23.9–28.0) vs. 24.1 (22.5–26.0) kg/m2, p = 0.001). Additionally, preoperative MQS in the sarcopenia group was significantly lower than that in the non-sarcopenia group (6.8 (4.2–11.6) vs. 9.6 (4.6–13.8), p = 0.002). p < 0.001). The estimated mean NRS of back and leg pain did not differ significantly between the groups throughout the study period.p < 0.001). When comparing both groups using a GEE model, there were no significant differences in the NRS for leg and back pain. The p-values of the interactions between the groups and times for back pain and leg pain were 0.347 and 0.684, respectively.To our knowledge, no studies have reported the impact of sarcopenia on PEBN in patients with LSS. Our results revealed that PEBN significantly decreased pain intensity up to six months after the procedure in patients with LSS regardless of sarcopenia.Due to an aging population, aging is now receiving increased social and medical attention. In elderly patients, frailty, such as weight loss or lack of physical activity, is a significant risk for geriatric diseases . In 1989Various studies on sarcopenia have recently been conducted due to an increase in the elderly population. The presence of sarcopenia is associated with poor outcomes after surgery ,22,31, iThere were some limitations in diagnosing sarcopenia using the CSA of the psoas muscle. However, several studies demonstrated that reduced CSA of the psoas muscle measured through CT or MRI may represent sarcopenia ,25. LoweLSS is known to be more prevalent in older individuals, as it is often associated with degenerative changes in the spine that occur with aging . The trePEBN is a safe and effective treatment for intractable lumbar radicular and back pain and functional improvements ,18,19,20Redundant nerve root and degenerative lumbar spondylolisthesis are generally associated with poor outcomes in surgery or pain procedures ,38,39. HRegarding demographic data, the BMI, age, sex, and MQS were statistically different between both groups. Several reports show that older adults tend to have low BMIs, which can cause muscle loss and bone density problems ,40. PatiOur study had several limitations. Firstly, physical functions measured via objective exams, such as gait speed and muscle strength, were not included in the evaluation of sarcopenia . HoweverPEBN may lead to considerable pain reduction for at least six months in patients with chronic LSS accompanying sarcopenia. PEBN might be considered for patients with chronic LSS regardless of sarcopenia being refractory to conservative treatments.


While posterior spinal instrumentation and fusion (PSIF) for severe adolescent idiopathic scoliosis (AIS) is the gold standard, anterior vertebral body tethering (AVBT) is becoming an alternative for select cases. Several studies have compared technical outcomes for these two procedures, but no studies have compared post-operative pain and recovery.In this prospective cohort, we evaluated patients who underwent AVBT or PSIF for AIS for a period of 6 weeks after operation. Pre-operative curve data were obtained from the medical record. Post-operative pain and recovery were evaluated with pain scores, pain confidence scores, PROMIS scores for pain behavior, interference, and mobility, and functional milestones of opiate use, independence in activities of daily living (ADLs), and sleeping.p = 0.03) and had fewer instrumented levels (p = 0.03). Results were significant for decreased pain scores at 2 and 6 weeks after operation , decreased PROMIS pain behavior at all time points , decreased pain interference at 2 and 6 weeks post-operative (p = 0.012 and 0.009), increased PROMIS mobility scores at all time points , and faster time to functional milestones of weaning opiates, independence in ADLs, and sleep .The cohort included 9 patients who underwent AVBT and 22 who underwent PSIF, with a mean age of 13.7 years, 90% girls, and 77.4% white. The AVBT patients were younger (In this prospective cohort study, the early recovery period following AVBT for AIS is characterized by less pain, increased mobility, and faster recovery of functional milestones, compared with PSIF.IV. Adolescent idiopathic scoliosis (AIS) affects 1–3% of U.S. adolescents . AlthougA recent meta-analysis comparing AVBT with PSIF found similar clinical outcomes, deformity correction, and mid-term Scoliosis Research Society-22 scores (SRS-22) . HoweverThe purpose of this study is to compare post-operative pain and functional recovery in AVBT versus PSIF using a prospective series of patients. We hypothesized that AVBT patients have significantly reduced post-operative pain and improved functional recovery up to six weeks after surgery because the procedure is less morbid to the osseous spine.This was a prospective observational study at a single academic institution. Institutional review board approval was obtained prior to commencement. Consecutive children aged 11–18 treated with primary multilevel PSIF or AVBT by a single senior surgeon for idiopathic scoliosis from May 2019 through April 2021 were eligible. Exclusion criteria included non-idiopathic scoliosis, history of chronic pain/opioid use, history of prior spine surgery, non-English-speaking, and unplanned re-admission or return to the operating room within six weeks of index procedure.®) pain-related tools (Pain Behavior and Pain Interference) were measured at 1, 2 and 6 weeks [Pre-surgical clinical data were obtained from the medical record. Cobb angles for curve magnitude were measured, and Risser scores were assessed when available from PA radiographs –18. Clin 6 weeks . These s 6 weeks –21. GlobFor inclusion in either the 2- or 6-week analysis, patients had to meet two of the following three criteria defined prior to study initiation: (1) completion of at least 50% of all surveys; (2) completion of at least 50% of the weekly check-ins; (3) completion of either the 2- or 6-week PROMIS measures (respectively). This minimum completion percentage was established in order to ensure the patients were appropriately engaged with the surveys and providing accurate responses. Patients have been followed for a minimum of 2 years after surgery.t test or the Mann–Whitney U test. Paired analyses were completed to compare change in outcome measures over time. Categorical variables were compared using the Chi-square tests. Categorical variables are reported as frequency and percentage; continuous variables are presented with a measure of central tendency (mean or median) and spread (SD or range). All comparative analyses were two tailed with alpha set at 0.05.Descriptive statistics were generated for demographic variables. Continuous variables were then analyzed using the student p = 0.03). The AVBT patients were also less skeletally mature, with lower Risser scores (2.1 vs. 3.5 out of 5) (p = 0.03). There was no difference among the AVBT and PSIF groups in terms of gender (p = 0.26) or ethnicity (p = 0.29). The mean magnitude of the major curves were 54.5 degrees. Pre-surgical curve magnitudes of those who underwent AVBT were significantly less (47.7 vs. 57.5 degrees) (p < 0.001). Those in the AVBT group had a mean of 7.2 instrumented levels, which was significantly fewer than the mean of 9.7 in the PSIF group (p = 0.03).Forty patients were enrolled. Nine patients were excluded after enrollment, including 5 who not complete the required surveys, 2 who canceled their surgery, and 2 patients who were excluded for return to surgery within 6 weeks. The two patients who had complications requiring return to surgery had undergone fusion surgery. There were 31 patients in the final cohort, 9 in the AVBT group and 22 in the PSIF group  and 6 weeks post-operatively   and sleeping through the night without waking in pain . Specifically, all AVBT patients were independent with ADLs by week 6 after operation compared with 25% of PSIF patients who remained dependent at this time point. Those in the PSIF group took twice as long to wean off opioids . Specifically, all AVBT patients were off opioids by week 3, whereas 10% (n = 2/19) of PSIF patients still were taking opioids at 6 weeks after operation  and 6 weeks . PROMIS pain interference scores were also lower at both 2 weeks  and 6 weeks . PROMIS mobility scores were significantly higher among AVBT patients as compared with PSIF patients at 1 week , 2 weeks  and 6 weeks , with higher scores representing greater mobility. Each of these differences also met the minimum clinically significant difference. There were no between-group differences in any of the additional measured outcomes at either 2 weeks or 6 weeks timepoint, including PROMIS global health, anxiety, positive affect, physical activity or strength impact .PROMIS scores were significantly lower in the AVBT group across each of the primary outcomes of pain interference and pain behavior, and significantly higher for mobility Table , Fig. 5.AVBT is an emerging treatment option for select patients with AIS. To date, there have been few prospective studies directly comparing patient-reported outcomes for patients undergoing AVBT versus those treated with PSIF. Our data show that AVBT patients have less pain and recover more quickly compared with PSIF patients. Specifically, those treated with AVBT had lower mean daily pain scores, faster time to discontinuation of opioids, earlier independent completion of ADLs, and less disturbances in sleep for the first six weeks after surgery. These findings were reflected across a number of validated patient-reported outcome scores, including lower PROMIS pain behavior and pain interference scores, and higher PROMIS mobility scores at 2 and 6 weeks post-operatively for AVBT patients. Notably, each of these findings surpassed the minimum clinically significant difference of 3 points for each pediatric PROMIS measure, further highlighting the value of this difference to patients and their families , 21.We chose a follow-up period of 6 weeks because this time period encompasses opioid use, highest pain and greatest disability.Our findings are consistent with prior reports that suggest long-term patient-reported outcomes for AVBT are as good as or better than those for PSIF , 22. QiuPain is the predominant concern for patients undergoing AIS surgery, as well as their parents , 24. HigThe principal limitation of our study is the small number of patients. This was due to the strict criteria for inclusion, in particular completion of surveys, which we also regard as a strength. In addition, the scope of our enrollment period was one year, which limits the number of patients who participated. We narrowed the time window to limit the impact of evolution of surgical technique for a novel procedure. Furthermore, a new procedure must be applied judiciously with strict inclusion criteria while long-term outcomes remain unknown; hence the small number of AVBT patients. Despite the small numbers, to our knowledge, this is the largest prospective study comparing perioperative pain between PSIF and AVBT. Additionally, here are different surgical indications for these two procedures, and as such, this comparison must be utilized and interpreted judiciously.Using prospectively collected data from a single-surgeon cohort, and applying validated outcome measures, our findings aid decision-making for the novel technique of AVBT, focusing on recovery in the early post-operative period. Although a small cohort, this study can add information to the growing literature on the equipoise in treatment recommendations between AVBT and PSIF .Patients treated with AVBT had less pain in the early post-operative period compared with those who underwent PSIF. AVBT patients were also quicker to achieve every measured functional milestone in the first 6 weeks post-operatively, and had improved PROMIS scores for pain interference, pain behavior and mobility. It must be noted that the indications for AVBT are more narrow than PSIF. These data can enhance decision-making regarding this novel procedure, AVBT, for which clinical equipoise remains.


This study was designed to identify the major musculoskeletal symptoms of individuals with obesity, to assess their health-related quality of life, and to evaluate the correlation between the musculoskeletal symptoms and the individuals’ health-related quality of life. Cross-sectional study. “Nordic Musculoskeletal Questionnaire” and “The Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36)”. In total, 41 subjects were evaluated, of which 90.15% were female. The mean age of the subjects was 40.78 ± 9.85 years and their mean body-mass index was 46.87 ± 8.08. All subjects reported musculoskeletal pain in at least one anatomical region and 80.49% had pain in three or more regions. The activity limitations due to pain were reported by 75.61% of them. The most affected regions by pain were the ankles and/or feet, lower back, knees and wrists/hands/fingers. The most associated regions with activity limitations due to pain were the ankles and/or feet, knees and lower back. The presence of pain showed a negative correlation with the domains physical functioning (PF), role-physical (RP) and body pain (BP). The activity limitations showed a negative correlation with the domains PF, BP, social functioning (SF) and role-emotional (RE). Our data showed a high prevalence of musculoskeletal pain and limitation in activities due to pain in obese subjects. The musculoskeletal symptoms had negative correlations with physical and mental components of the health-related quality of life, highlighting the importance of ensuring that patients with obesity have access to interdisciplinary care, for the prevention and rehabilitation of musculoskeletal disorders. The incidence of obesity has increased in recent decades, and obesity has become a major global health challenge . In BrazA higher prevalence of musculoskeletal symptoms affecting mainly the lower limbs has been reported in obese individuals ,5. Some Some studies have reported that obesity has a negative impact on the patients’ health-related quality of life ,11 but oThe purpose of this study was to identify the major musculoskeletal symptoms of individuals with obesity grades II, III and IV, to assess their health-related quality of life, and to evaluate the correlation between the musculoskeletal symptoms and the patients’ quality of life. This information will be useful for the development of preventive and therapeutic measures to improve the musculoskeletal symptoms and quality of life of obese patients.This was a cross-sectional study and was approved by the Ethics Committee of the Universidade Federal do Espírito Santo . The data were collected from April to December 2011. The study population consisted of all patients aged over 18 years who underwent preoperative consultations for bariatric surgery in a Brazilian University Hospital during the study period (n = 41).During the physical therapy consultation of the patients were collected general data, such as age, sex, height, weight, marital status, education, occupation and lifestyle habits. Two questionnaires were administered by the researchers, who were properly trained so that the assessments were standardized. The first questionnaire was the validated Brazilian version of the Nordic Musculoskeletal Questionnaire (NMQ) ,14, whicImmediately after, we used “The Medical Outcomes Study 36-Item Short-Form Health Survey” (SF-36), which was validated and translated into Portuguese ,18, for Data were analyzed using the Statistical Package for the Social Sciences (SPSS) 18.0, IBM. To measure the degree of association between two metric variables, we used the correlation coefficient. The Shapiro-Wilk test was used to determine whether the data distribution was normal. For variables where the normal hypothesis was not rejected, the t-test was used to analyze the means . For the domains where the assumption of normality was rejected, we applied the nonparametric Mann-Whitney test. To assess correlations, the Spearman correlation coefficient was used. The data were expressed with standard deviations (SD) and differences were considered significant if p < 0.05.2 and ranged from 35.73 to 65.02 kg/m2. All subjects were followed up by the health interdisciplinary team of the Bariatric Surgery Program in the hospital.We evaluated 41 obese subjects (grades II to IV), of whom 37 (90.2%) were female and four (9.85%) were male, candidates to bariatric surgery. The average age of the patients was 40.78 ± 9.85 years and ranged from 25 to 65 years. The patients’ mean BMI was 46.87 ± 8.08 kg/mThe most frequent comorbidities were systemic arterial hypertension (SAH), which was observed in 31 subjects (70.7%), and diabetes mellitus (DM), which was observed in 16 subjects (39%). All individuals with DM also had hypertension. In terms of physical activity, 68.3% reported that they did not participate in any physical activity. Of the 28.3% who performed some activity, 26.8% participated in walking, with frequency ranging from two to five times a week, and 2.4% participate in aquatic exercises, with frequency ranging two to five times a week.In the 12 months preceding the questionnaire, 100% of subjects reported pain in at least one anatomical region and 80.49% had pain in 3 or more anatomical regions. In the previous 7 days, 92.68% reported pain in at least one anatomical region and 60.98% in 3 or more regions. The limitation of activities due to pain in the previous 12 months was reported by 75.61% of patients. The anatomical regions most affected by pain in the previous 12 months were the ankles/feet (87.80%), lumbar region (68.29%) and knees (68.29%). In the preceding 7 days, 70.73% had pain in the ankles/feet, 53.66% in the lumbar region, 46.34% in knees and 46.34% in the knees, wrists/hands/fingers. The regions that were most frequently associated with activity limitations due to pain were the ankles/feet (46.34%), knees (43.90%) and lower back (41.46%). The prevalence of pain by anatomic region is presented in detail in There was no statistically significant correlation between BMI and musculoskeletal symptoms. There was also no significant correlation between age and musculoskeletal symptoms.The presence of pain in the previous 12 months showed a statistically significant correlation with the domains PF and BP. These correlations were negative, indicating that the greater the pain, the worse the quality of life in these domains. The presence of pain in the previous 7 days showed a significant negative correlation with the domains PF, RP and BP . Table 5The results showed that all individuals with obesity of grades II to IV and who were candidates for bariatric surgery had musculoskeletal symptoms, and all subjects reported pain in at least one anatomical region in the 12 months preceding the assessment. The prevalence of pain in the 7 days preceding the assessment was also high (92.68%). A similar prevalence was found in another study, in which 100% of the obese individuals evaluated during preoperative bariatric surgery had musculoskeletal symptoms in at least one region of the body .The current study demonstrated that the anatomical areas most often affected by pain in the 12 months and 7 days preceding the assessment were the ankles and/or feet, lower back, knees and wrists/hands/fingers. A similar prevalence of musculoskeletal symptoms in the ankles/feet and knee was shown in a study conducted in obese patients before and after bariatric surgery. Six months after surgery, the subjects experienced a marked reduction in both frequency and intensity of musculoskeletal pain, which strengthens the association between the symptoms and obesity. However, the study used the modified NMQ, considering only the questions about the presence of pain in the lower limbs in the previous 7 days . In addi2 is an important risk factor for the incidence of knee osteoarthritis , knees (43.90%) and lower back (41.46%). These findings corroborate Larsson’s conclusion that high BMI value, age and lower body pain could predict functional limitations in obese women . Further. showed that obesity was related with impairment in both physical and mental components of health-related quality of life in Australian adults followed over 5 years (With regard to quality of life, a study that also used the SF-36 showed a relationship between quality of life and obesity and identified an association between excess weight and low values in the domains PF, RP and BP . We must 5 years . One facA study conducted with 5,633 people in Sweden showed that the impact of obesity differs by age with relation to physical and mental health domains . In our We found no statistically significant correlation between the SF-36 and BMI in our study. However, in the similar study mentioned earlier , there wSach and cols. reported that the higher the BMI, the worse the HRQL of individuals compared to those with normal BMI . CameronSome studies in the literature have reported that musculoskeletal pain is a predictor of poor health-related quality of life in obese subjects ,12,31, bThe present study showed a significant negative correlation between the presence of pain and the reduction in quality of life related to health in the domains PF, RP, BP. In other words, the musculoskeletal pain in these obese patients had a negative impact on their quality of life in these domains, suggesting that in our study, the physical health component of the individuals’ health-related quality of life was more affected by pain than the mental health component. In addition to this, the results also indicated that the limitation of activities by pain had a statistically significant negative correlation with the domains RP, BP, SF and RE, meaning that limitation of activities due to pain negatively affected both the physical and the mental components of health-related quality of life. Such knowledge can provide evidence to support the adoption of primary, secondary, tertiary health care prevention, and interdisciplinary rehabilitation, to ensure more effective interventions for these patients.The major limitations of this study were the small sample size and the fact that the study was conducted in a single institution. Due to both of these features, generalized conclusions cannot be drawn from this study. Another limitation is that the causes of the musculoskeletal symptoms were not investigated by clinical and radiological evaluation but only by questionnaire. Finally, we did not evaluate other comorbidities that could interfere with the patients’ health-related quality of life.In conclusion, individuals with obesity grades II, III and IV who were candidates for bariatric surgery showed high prevalence of musculoskeletal symptoms and of activity limitation by pain. They also had low scores in all domains of health-related quality of life. Furthermore, the presence of musculoskeletal symptoms had a significant negative correlation with the domains PF, RP, BP, SF and RE. This suggests that the physical and mental components of health-related quality of life were affected by musculoskeletal symptoms.


Pain is a common symptom in stage IV non-small cell lung cancer (NSCLC). The objective of the study was to examine the use of interventions and factors associated with interventions for pain. A population-based cohort study in Ontario, Canada was conducted with patients diagnosed with stage IV NSCLC from January 2007 to September 2018. An Edmonton Symptom Assessment System (ESAS) score of ≥4 defined moderate-to-severe pain following diagnosis. The study cohort included 13,159 patients, of which 68.5% reported at least one moderate-to-severe pain score. Most patients were assessed by a palliative care team (85.4%), and the majority received radiation therapy (73.2%). The use of nerve block was rare (0.8%). For patients ≥65 years of age who had drug coverage, 59.6% received an opiate prescription. Patients with moderate-to-severe pain were more likely to receive palliative assessment or radiation therapy compared to patients with none or mild pain. Patients aged ≥70 years and with a greater comorbidity burden were associated with less likelihood to receive radiation therapy. Patients from rural/non-major urban residence and with a greater comorbidity burden were also less likely to receive palliative care assessment. Factors associated with interventions for pain are described to inform future symptom management in this population. Lung cancer leads in cancer incidence and mortality worldwide . Nearly Palliative care is commonly involved to help providing pain management strategies in cancer patients. First-line treatment for cancer pain often includes analgesics, such as opioids. If pain is related to bony metastasis, palliative radiotherapy may be considered. For patients who do not experience relief with first-line treatments, patients may be referred to interventional anesthesia for consideration of nerve blocks .Patient-reported outcomes (PROs) describe the burden of symptoms from the patient’s perspective. Routine documentation of PROs has been associated with early identification of symptoms, improved quality of life and improved survival outcomes ,8,9,10. Overall symptom burden using ESAS in stage IV NSCLC in Ontario has been previously reported by our research group, which found moderate-to-severe symptoms were prevalent and peaked at diagnosis while remaining high during the first year of follow-up . The aimRoutinely collected data held at ICES  in Ontario, Canada were used to conduct this population-based cohort study. The study was conducted according to approval by the Research Ethics Board at Sunnybrook Health Sciences Centre .Patients with NSCLC were identified using the Ontario Cancer Registry (OCR). ESAS scores were obtained from the Cancer Care Ontario Symptom Management Reporting Database that has systematically collected questionnaires from outpatient cancer clinic visits at regional cancer centers beginning in 2007. Demographic data were retrieved from the Ontario Registered Persons Database (RPDB) and the Canadian Census. Billing claims for physician services were obtained from the Ontario Health Insurance Plan (OHIP) database. The Cancer Activity Level Reporting (ALR) was used to capture information regarding radiation treatments. Information from hospitalizations was retrieved from the Canadian Institute for Health Information Discharge Abstract Database (DAD), while emergency room visits were retrieved from the National Ambulatory Care Reporting System (NACRS). Outpatient prescriptions dispensed to individuals aged ≥65 years are captured in the Ontario Drug Benefit (ODB) database with an error rate of <1% , and thiOur study cohort included patients diagnosed with stage IV NSCLC from January 2007 to September 2018 using the OCR. Exclusion criteria included age less than 18 years, no ESAS scores were collected following diagnosis or if the patient had another cancer diagnosis 5 years prior to diagnosis or during follow-up. Patients were followed from the date of diagnosis to date of last contact, death or end of the study timeframe (30 September 2019).Baseline characteristics were measured at the time of diagnosis, including age, sex, rural residence, neighbourhood income quintile and comorbidity burden. Other factors included the year of diagnosis and number of ESAS questionnaires. Systemic therapy was defined as patients who had more than cycle of chemotherapy/immunotherapy. Death was defined by any cause recorded in the RPDB and administrative datasets, such as DAD and NACRS, during the follow-up period. The Rural Index of Ontario was used to measure rural residence. This index considers population size, population density and healthcare resources to stratify data into the following categories: major urban (0–9), non-major urban (10–44) and rural (45–100) . NeighboModerate-to-severe pain was defined by an ESAS score ≥4, which has been previously validated to identify patients with significant symptoms . PatientPalliative care was defined by evidence of an assessment from OHIP, DAD or NACRS. Palliative care was further stratified by inpatient, outpatient and both categories. Radiation therapy and nerve block were identified from ALR and OHIP, respectively. These interventions were measured by a diagnostic code at any time from diagnosis to end of follow-up. The use of opiates was evaluated in patients ≥65 years of age who had coverage for prescription drugs through the ODB program. This included the dispensing of codeine, fentanyl, hydromorphone, morphine, oxycodone and tramadol.Baseline characteristics were presented for continuous variables in medians/interquartile ranges (IQR) and for categorical variables in counts/percentages. These characteristics were further stratified by patients who reported moderate-to-severe and none or mild pain scores and were then compared using standardized differences. A standardized difference >10% was considered as a meaningful difference. We also calculated the proportion of patients who underwent interventions, including palliative care assessment, radiation therapy, nerve block and use of opiates, for patients with moderate-to-severe pain scores and for patients with none or mild pain scores. Intervention use was also compared using standardized differences. Factors associated with the different intervention use among patients with moderate-to-severe pain were explored using multivariable modified Poisson regression models with robust error variance estimator for rates of the outcomes; the use of a Poisson model is a good approximation to binomial distribution without the convergence issues that are associated with negative binomial models. The relevant covariates controlled for in the model included age, sex, rural residence, neighborhood income quintile, comorbidity burden and year of diagnosis. These variables included in the model were determined a priori based on clinical relevance. The results are reported as relative risks (RR) and 95% confidence intervals. All analyses were conducted using SAS, version 9.4 .In total, 13,159 patients diagnosed with stage IV NSCLC from January 2007 to September 2018 met our inclusion criteria . The medn = 9008). Patients with moderate-to-severe pain scores were more likely to be younger  30%) and completed ESAS questionnaires more frequently . Patients with moderate-to-severe pain also more commonly received systemic therapy after diagnosis . Other baseline characteristics, including sex, rural residence, income quintile and comorbidity burden, were not significantly different for patients who reported moderate-to-severe pain scores as compared to patients who did not report moderate-to-severe pain scores.The baseline characteristics stratified by ESAS pain score are summarized in The median time from diagnosis to first moderate-to-severe pain score was 50 (IQR: 25–134) days, and the median time from first moderate-to-severe pain score to death was 131 (IQR: 55–291) days. Death was not significantly different in patients with moderate-to-severe pain scores compared to patients with none or mild pain .Interventions based on ESAS pain scores are summarized in In an analysis of opioid use, which was restricted to 8061 patients ≥65 years of age who had prescription coverage through the ODB program, 59.6% received an opiate prescription. There was no significant difference in opiate prescriptions in patients with moderate-to-severe vs. none or mild pain scores .For those patients who received palliative care assessment, further stratification revealed that 2.4% received inpatient palliative care, 58.9% received outpatient palliative care, and 38.7% received both inpatient and outpatient palliative care. When characterizing by the type of palliative care that was received at the first setting, 17.6% of patients received inpatient first, while 82.4% received outpatient first. Palliative care stratified by type for patients with moderate-to-severe pain vs. none or mild pain is also reported in The results from the multivariable analysis to identify factors to receiving pain interventions are reported in Greater comorbidity burden was associated with less likelihood to receive palliative care (RR 0.96 (0.93–1.0)) and radiation therapy (RR 0.90 (0.85–0.96)) in patients with moderate-to-severe pain. In addition, patients with moderate-to-severe pain from a rural (RR 0.86 (0.83–0.90)) or non-major urban (RR 0.95 (0.94–0.97)) residence were also less likely to receive palliative care. Overall, the association between neighborhood income quintile and intervention use was not significant. The use of palliative assessment increased (RR 1.003 (1.000–1.005)), while the use of radiation therapy decreased with year of diagnosis (RR 0.970 (0.966–0.974)).In this population-based study based in Ontario, Canada, 68.5% of stage IV NSCLC patients reported at least one moderate-to-severe ESAS pain score. Although the administrative data analyzed did not have sufficiently granular information on the etiology of pain, our findings are consistent with previously reported findings ,22,23,24Bubis et al. reported on the symptom burden in the first year of cancer diagnosis with a similar methodology in our healthcare system and found that 51% of respiratory cancers reported a pain ESAS score ≥4. The pain prevalence was higher than various other cancers compared, including GI, breast, gynecologic, genitourinary and CNS .When compared in the metastatic context, NSCLC reported a higher prevalence of patients who reported moderate-to-severe ESAS pain scores compared with esophageal and gastric cancers ,22. SimiOur analysis showed that patients with moderate-to-severe pain were more likely to have a younger median age. Previous studies have also shown that older lung cancer patients were less likely to report pain, which was consistent with our results ,26,27. FMost patients in our cohort were managed with palliative care (85.4%). Quinn et al. reported that the delivery of palliative care among cancer patients in their last year of life was delivered in the following settings: 1.5% inpatient, 6.9% outpatient, 3.4% home-based, 4.9% case management and 83.3% multiple locations. A total of 15.3% of patients received their first palliative care in setting of a hospital, which was similar to our reported inpatient rate of 17.6% . Early pESAS has the potential role to identify patients early for palliative care. A retrospective-matched cohort study in Ontario found ESAS assessments were associated with a 6% increase in palliative care services in cancer patients . CliniciOur study also demonstrated that patients with greater comorbidity or who were not from a major urban residence with moderate-to-severe pain were less likely to receive palliative care. There is variation of palliative care services across the province of Ontario. This relationship was previously reported in a study by Tanuseputro et al. who found that patients living in rural regions in Ontario were less likely to receive palliative care (OR 0.80 (0.78–0.83)) . In a stRadiation therapy was a common therapeutic intervention for pain in our cohort (73.2%). Our findings are consistent with the utilization rates of palliative radiation among patients with metastatic NSCLC in the United States, which have been reported to be 50% or greater ,40. OldeThe negative association between age and palliative radiation was also reported in a previous study in Ontario amongst all cancers . HoweverSymptom management is important in the metastatic lung cancer population considering the high proportion of patients diagnosed at this stage and the associated poor prognosis. In this study, 4.3% of patients who reported moderate-to-severe pain did not receive any intervention for pain highlighting the unmet need in this population. With the shift to virtual care since the COVID-19 pandemic, there is an opportunity to utilize patient-reported outcomes to improve care for patients. This includes the virtual collection and monitoring of ESAS scores. During the pandemic, virtual collection of ESAS though emailing a fillable PDF form was reported in a prospective study at Princess Margaret Hospital in Toronto, Ontario . Other pHigh symptom scores can be used to trigger automatic assessments of patients. The Lurie Cancer Center Gynecologic Oncology outpatient clinic linked PRO assessments to the electronic healthcare record. Patients completed computer adaptive tests to assess symptoms, and clinicians were notified of elevated scores and triaged to social work, health educators and dieticians depending on the concern . A similESAS can also be used to triage patients for home-based palliative care following a referral. Dhiliwal et al. completed a pilot of a triage coding system where high priority (ESAS ≥ 7) were seen within 3 days, medium priority (ESAS 4–6) were seen within 10 days and low priority (ESAS 0–3) were seen within 15 days . This haOur study has several strengths. First, we used data from a province-wide implementation of ESAS patient-reported outcomes to routine clinical care, allowing for a large sample size. Second, in the setting of universal healthcare coverage, our study diminished cofounders, such as direct financial barriers preventing patients receiving interventions for pain. Limitations of our study are also recognized. First, a large proportion of patients were excluded as ESAS scores were not collected. As described previously, patients who did not complete any ESAS were more likely to be older, to have higher comorbidity and to not receive any active cancer treatment . Therefore, we may be underestimating the true pain burden in the population. Second, our findings regarding nerve block were limited by the small sample size of patients who underwent this intervention in our study cohort. Third, we were restricted by administrative data. For example, we only had data available to describe opiate prescription in the ≥65 years age cohort. As a result, we are unable to accurately characterize opioid prescription in younger adults diagnosed with stage IV lung cancer. Additional variables that could have helped better define the cohort (such as ethnicity or biomarkers) or describe other cancer interventions were not available. In addition, location descriptions of patient pain were not available. Lastly, we analyzed the symptom burden using the ESAS score at one time point. As a result, we did not follow pain across the course of disease progression and treatment.A majority of patients with stage IV NSCLC reported moderate-to-severe pain (68.5%). Most patients received palliative care assessment or radiation therapy, while nerve block was rare. Patients from rural or non-major urban residences and patients with more comorbidities were less likely to receive palliative care assessment, while patients with older age and more comorbidities were less likely to receive radiation therapy. The data presented in this study help to identify gaps in our cancer care and suggest a continued need for pathways to ensure equitable supports for patients with a high pain burden.


P = .038). The Tampa Scale score improved significantly in both groups . Pain severity and pain threshold at all sites showed significant posttreatment improvements in the GII. Significant posttreatment changes were only found for GI in terms of pain severity and the most painful joint . Significant changes were observed in kinesiophobia, pain severity, and pain threshold in the most painful joint 3 and 5 days after Siwan traditional therapy. Despite the nonsignificant differences in all parameters between the 2 groups, all the measured parameters produced favorable results after 5 days of treatment, suggesting the need for a long-term effect investigation.Rheumatoid arthritis (RA) is a long-term autoimmune disease characterized by intra- and extra-articular manifestations. Sand therapy is traditionally indicated for RA, chronic pain, skin diseases, and musculoskeletal disorders. Many places in the world use sand therapy, including Siwa, which is a famous place in Egypt. This study investigated the exposure time to Siwan traditional therapy as a factor influencing central sensitization, pain severity, pain threshold, and kinesiophobia in RA by measuring the central sensory inventory (CSI), visual analogue scale, pressure algometer, and TAMPA kinesiophobia scale, respectively. Twenty-four patients with RA were recruited from 6 traditional healing centers, 24 RA patients were recruited and randomly assigned to 2 equal groups (GI and GII). The first received Siwan traditional therapy for 3 days, while the second received the same program for 5 days. The results revealed a significant difference in CSI between pre- and posttreatment within the GII ( The climate is extremely dry for almost 6 months of the year. The maximum precipitation is 9 mm in 1 month of the year. Precipitation is 2 mm for the rest of the year. The isolation and unique climate of Siwa were preserving factors for some traditional old therapies like psammotherapy, which is an old practice extending back to the period of Roman civilization. Traditionally, it has been used in the form of hot sand baths, mostly heated by the sun, for therapeutic purposes. This depends on the traditions of the people living in that place and the availability of natural resources such as sand. Even today, several countries are still using sand baths. Examples include Portugal, Japan, Egypt, and many other countries.–9 Psammotherapy is commonly indicated for osteoarthritis, posttraumatic injuries, osteoporosis, gout, fibromyalgia, and chronic rheumatic conditions.The Siwa is an oasis located in the western desert of Egypt. It covers an area of 7500 km RA also affects other systems in the body through its immune-mediated inflammatory effect, characterized by spontaneous and symmetrical pain in the affected joints due to inflammation. Joint stiffness, particularly after immobility, such as after sleeping, is another characteristic of the disease. Movement within normal ranges and pressure at the joint margins increase pain severity.,13 However, mild exercise, low humidity, and warming of the affected area improved the symptoms of RA.Rheumatoid arthritis (RA) is a long-term autoimmune disease characterized by intra- and extra-articular manifestations. RA is thought to affect between 0.5% and 1% of the population worldwide. Traditionally, rheumatic pain is assumed to be directly related to peripheral inflammation; therefore, physicians have considered it an inflammatory marker. Disease-modifying antirheumatic drugs have been reported to significantly decrease pain. However, persistent pain in many patients has been reported, even with treatment. Additionally, a difference between the inflammation assessed by physicians and patient-reported pain has been reported in other studies.,18 Chronic pain differs from acute pain in that it typically lasts longer and is more likely to be influenced by input from the central nervous system (CNS), whereas acute pain is frequently caused predominantly by inflammation and/or damage to peripheral tissues .Pain is the primary trigger for seeking medical care. Patients with chronic pain visit their primary care clinician more often. Pain evaluation also helps determine the modifications needed in the patient’s treatment plan. However, pain is a subjective variable and is very difficult to measure.,21 The mechanisms for experiencing pain are not fixed but rather dynamic. The term “plasticity of the nervous system” is used to describe the innate ability of the nervous system to change and adapt. Damage to peripheral tissues can trigger a plastic response in the CNS, which can extend pathological pain.Consistently elevated nociceptive impulse activity, similar to that observed in RA, may cause peripheral and central sensitization, elevated sympathetic nervous system activity, and disruption of endogenous inhibitory systems. The phenotype of neurons can be altered such that they transmit pain signals instead of pressure or touch signals. New sprouting of the dorsal horn may result in an expanded receptive field or formation of new synapses. The number of pain-transmitting receptors on the cell surface may either increase or decrease. The threshold at which neurons fire may change, and there may be disruptions in the circuit that control pain amplification or pain inhibition.,27 This activity occurs continuously in both the peripheral nervous system and CNS.Changes in both cells and their associated neurotransmitters are what we mean when discussing plasticity. A better understanding of how pain, kinesiophobia, and physical function performance are related will be important for developing new ways to treat diseases and educate patients and their families.In many musculoskeletal disorders, pain-related fear of movement or kinesiophobia plays a major role in the onset, persistence, and exacerbation of chronic disability. Efficacy, safety, route of administration, and treatment costs are important determinants in the choice of treatment. Although different treatment plans and monitoring can help patients achieve early and long-lasting clinical and radiographic remission, the high cost of drugs and limited healthcare budgets make it difficult for people to receive RA treatment. The high cost of treatment, both directly and indirectly, makes it difficult for patients to pay their bills and lower their quality of life. Increasingly, patients are visiting rheumatologists who expect them to treat pain as a discrete symptom. Currently, pain treatment is more holistic, considering the patient’s biopsychosocial needs rather than only the patient’s physical needs. Egypt is a developing country with limited financial resources for both individuals and the healthcare system. RA is a chronic disease that presents a heavy burden on the shoulders of patients. Therefore, many patients with RA prefer traditional medicines. They consider it a healing experience in a way that many patients plan for annually. From this point of view, traditional Siwan therapy is cheaper, safer, and more effective. Traditional healers in Siwa suggest the duration of treatment according to their experience, which depends mostly on their history of estimated improvement. However, it is the patient’s decision to accept or refuse this suggestion according to his tolerance and/or financial status. Healers traditionally suggest 3, 5, or 7 hot sand baths for RA once a day. To the best of our knowledge, only 3 previous studies have been performed in Siwa and proved the effect of Siwan traditional therapy on RA.,34,35 The fourth study investigated some of the risk factors associated with hot sand. None of the previous studies have discussed the different factors affecting the treatment protocols followed in the Siwa. Pain is the most common complaint in patients with RA. The current study is a baseline for a future cohort study that aims to establish the effect of such therapy. This helps determine whether the number of treatment sessions is a variable affecting treatment outcomes. It also provides information about pain intensity, kinesiophobia, and pain threshold changes due to hot sand.RA usually requires long-term treatment, with associated risks of drug toxicity. They were assigned to 2 groups. Group (I) consisted of 15 patients who received Siwan therapy for 3 days; and group (II) consisted of 15 patients who received the same treatment for 5 days. The patients’ ages ranged from 30:60 years, and all had chronic pain (> 6 months). Before the study, patients were on stable doses of disease-modifying antirheumatic drugs for 6 weeks and nonsteroidal anti-inflammatory drugs for 2 weeks. Patients were required to have a pain score between 30 and 70 on the present pain intensity scale. Corticosteroid injections were not allowed during the 4 weeks prior to the study. Informed consent was obtained from all the subjects involved in the study. Three patients did not finish the treatment. They traveled back home for personal reasons. Two patients traveled home after treatment before the final assessment. One patient finished her treatment but refused to continue in the research second assessment with no specific reason. Finally, Group (I) consisted of 12 patients who received Siwan therapy for 3 days; and group (II) consisted of 12 patients who received the same treatment for 5 days as shown in Figure Traditional Siwan therapy is performed only for 3 month a year, starting from mid-June until the end of the first week of September. In the current observational cross-sectional study, 50 patients with RA were recruited from 6 traditional healing centers in Siwa. Thirty patients met the inclusion criteria. However, 24 patients (n = 24) were included in the final analysis. Eligible individuals were diagnosed with RA according to the 2010 American College of Rheumatology/European Leaguen Against Rheumatism classification criteria.t-tests (means: difference between 2 independent means-two groups), type I error , type II error (1-βeta = 90%), and effect size d = 1.42857 for the main variable outcomes. Considering a 15% drop out rate, the appropriate sample size effect or this study included 24 patients (12 patients per group).This study’s sample size was determined using G*power 3.1.9  for two-tailed test. Sample size calculation was based on •Pain severity was measured using a Visual Analogue Scale: a Visual Analogue Scale is typically a horizontal line 100 mm long that the patient marks to represent his perception of the current pain status.• It was developed as a comprehensive screening tool with high reliability to determine whether a CS component exists or not.,40 There are 2 parts to CSI. Part A, which is used to measure CS symptoms, is made up of 25 self-reported questions about physical and emotional symptoms. Each question was scored from 0 to 100, with 0 being the best score and 100 being the worst. A 5-point Likert scale  was used to rate each item. Part B checked for a history of specific disorders, including 7 different CS syndromes . There is strong evidence that CS is involved in these 7 disorders. The CSI Part A score was divided into 5 groups based on the severity of the condition: subclinical (scores between 0 to 29), mild (30 to 39), moderate (40 to 49), severe (50 to 59), and extreme (scores between 60 to 100).The Arabic version of the Central Sensitization Inventory was used to measure central sensitization. CSI is a tool that helps people identify signs of nociplastic pain.•Kinesiophobia was measured using the Arabic version of the Tampa kinesiophobia scale to assess fear of reinjury associated with physical movement. Respondents rated 17 items on a 4-point scale ranging from (1 “strongly disagree” to 4 “strongly agree”). The total score ranges from 17 to 68, with higher scores indicating greater fear of movement or reinjury.• Pressure is one of the most common stimuli used to test pain thresholds in RA because it is thought to be the most reflective of arthritic pain.Pain thresholds were measured using an algometer at the third metacarpophalangeal metacarpophalangeals (MCPs) joints, wrist, and most inflamed joint.pm When the air temperature was 40:45 °C. Traditional healers usually dug a shallow hole in the sand, with dimensions of 20:40 cm deep, 80 cm wide, and 1:2 m in length. The hole is dug in the early morning at 10 am until the time of the session for heating the sand using sun rays. Before starting the sand bath, patients were instructed to avoid applying topical cream or lotion. They were also notified that this intervention would leave their body dusty and that they were not allowed to bath until the end of the 3 or 5 sessions.The most beneficial time for a sand bath is during the summer months in June, July, and August, as the sun is very hot. Sand bathing was performed in the afternoon at 1:4 During the sand bath, the patient was asked to lay down in the hole and was covered to the neck level with hot dry sand from the surface of the desert which is 75 to 82 °C in temperature. This takes approximately 10 to 15 minutes or according to the patient’s tolerance, but not more than 30 minutes. When the sand became wet from perspiration, it was replaced with hot-dry sand. Ten to 20 cm under the sand surface, the sand temperature was 50 to 60 °C. Immediately after the sand bath, the patient was wrapped carefully in a blanket and placed in a well-sealed tent located close to the hole for 15 minutes or according to patient tolerance. In the tent, the patient’s body relaxed and returned to its normal condition. Wrapping protects the patient from cold air drafts, which can lead to adverse effects, such as muscle soreness and headache. Patients were provided with many hot liquids  to prevent dehydration. Drinking water is prohibited immediately after the sand bath. Patients were instructed to continue drinking fluids until their bodies were replenished with dehydration. The patients were instructed to lie down until the body was adjusted to the lower environmental temperature. They were also asked to wipe the sand off their body and change their clothes when sweating on their shirt dries. Hot water was used to wash hands and face. water anywhere else in their bodies is avoided. Cold, fans, and air conditioners are prohibited during treatment days. On the final day of the sand baths, the traditional healer gave the patient a full-body massage using olive oil.P < .05) after removing outliers that were detected by box and whisker plots. Additionally, Levene test for the homogeneity of variance revealed a significant difference (P < .05). These findings allowed us to conduct both parametric and nonparametric analyses. The data were not normally distributed, and nonparametric analyses were performed. Statistical analysis was conducted using the 25th version of the Statistical Package for the Social Sciences . Quantitative data are expressed as means and standard deviations, and qualitative data are expressed as numbers and percentages. The Wilcoxon signed-rank test was used to compare pre- and posttreatment within 3-days group and 5-days group for pain severity and pain threshold. The Mann–Whitney U test was used to compare GI and GII pre- and posttreatment for pain severity and pressure algometer variables. The chi-square test was used to compare CSI and Tampa variables between the groups. All statistical analyses were significant at the level of significance (P ≤ .05).Data were examined using the normality assumption test and homogeneity of variance. Normality test of the data using the Shapiro–Wilk test was used, which indicated that the data were not normally distributed (P > .05) in patient demographic data for age (P = .116), disease duration (P = .248), gender (P = .615), academic level (P = .799), medication history (P = .414), or Siwan traditional therapy history (P = 1.000) between the 3-days group (G I) and 5-days groups (G II)  were randomly assigned to 2 groups (12 patients/group). There were no significant differences  between pre- and posttreatment within 3-days group. However, there was a significant difference in CSI  between pre- and posttreatment within 5-days group. The Tampa Scale distribution was significantly affected (P > .05) by time within the 3-days group (0.014) and 5-days group (P = .004).The statistical analysis (time effect) for CSI and Tampa Scale variables within each group Table  revealedP = .675; P > .05) and posttreatment  due to the group effect (Table P = .615) and posttreatment (P = 1.000).There was no significant difference between the 3-days group and 5-days group in CSI at pretreatment (ct Table . MoreoveP < .05) decrease in pain severity and increased pain threshold in the most painful joint posttreatment compared with pretreatment within GI  and GII . There were no significant differences between pre- and posttreatment within the GI in the right pressure pain threshold for the 3rd MCP (P = .182) and wrist (P = .530). However, there was a significant (P < .05) increase in the 3rd MCP (P = .034) and wrist (P = .003) posttreatment compared with pretreatment in GII. In the GI group, the left pain threshold did not differ significantly (P > .05) between pre-and posttreatment for 3rd MCP (P = .084) and wrist (P = .182). In contrast, the time effect in the 5-days group had a significantly (P < .05) higher left pain threshold of 3rd MCP (P = .005) and wrist (P = .012) posttreatment than pretreatment. These significant decreases in pain severity and increases in pain threshold in the 3rd MCP, wrist, and most pain posttreatment were more favorable of rheumatoid patients in the 5-days group than 3-days group. Moreover, the 5-days group improved higher decrease in pain severity and increased pain threshold in the most painful, right 3rd MCP, right wrist, left 3rd MCP, and left wrist  than those in the 3-days group . Pairwise comparison tests (group effect) for pain severity and pain threshold (right and left) variables between both groups (Table P > .05) in the pretreatment of pain severity (P = .396), pain threshold in the most painful (P = .332), right 3rd MCP (P = .065), right wrist (P = .054), left 3rd MCP (P = .910), and left wrist (P = .159) between the 3-days group and 5-days group. The same trend (P > .05) was observed posttreatment for pain severity (P = .581) and pain threshold in the most painful (P = .684), right 3rd MCP (P = .261), right wrist (P = .952), left 3rd MCP (P = .785), and left wrist (P = .412) between the 3-days group and 5-days group.Pairwise comparison tests (time effect) for pain severity and pressure algometer variables within each group Table  showed t Although sand baths have been used to treat RA for centuries, there has not been much scientific investigation of their efficacy. There is also a lack of a perfect choice of treatment dose for each pathological condition in traditional Siwan therapy. The purpose of this observational cross-sectional study was to determine the efficacy of such therapy in reducing pain, pain threshold, central pain, and kinesiophobia in patients with RA. It also investigated whether exposure time can affect treatment outcomes by comparing the 3-day group to the 5-day group. The current study showed that central pain in both groups improved significantly in GII (5-day group) but not in GI (3-day group). Additionally, in both groups, a significant decrease in pain severity was found as well as a significant increase in pain threshold at the most painful joint. When comparing the 2 groups, there were no significant difference. Regarding the pain threshold at the 3rd MCP and wrist, nonsignificant improvement was found in GI, while significant improvement was found in GII.One in 4 people around the world has chronic pain conditions, and many of them have musculoskeletal causes. Central sensitization syndrome was present in 41% of the patients with RA. A longer duration of symptoms is associated with a lower pressure pain threshold, suggesting that centrally mediated mechanisms evolve over time.Chronic inflammatory pain arises when inflammatory mediators are not neutralized, and the overexpression of proinflammatory cytokines and chemokines leads to peripheral and central sensitization.Changes in pain intensity, central pain, and pain threshold can be attributed to the hyperthermia effect of heated sand on the skin’s receptors and vessels. There is a complex communication network between the spinal cord, CNS, immune-endocrine system, and the skin is a key neuroendocrine organ that synthesizes and secretes numerous neurotransmitters and peptide substances that modulate inflammation, immune responses during host defense, pain, and pruritus. TRPV1, a member of the TRP vanilloid family, is activated by inflammatory mediators that induce hyperalgesia and thermal stimulation at temperatures >43°C which are achieved by the hot sands of Siwa. Many studies refer to TRPV1 role in modulating pain conversion, regulating brain synaptic transmission and plasticity. TRPV1 is effective in several neurological and psychiatric disorders, including depression, anxiety, and depression.–54Transient receptor potential (TRP), a protein receptor dispersed widely in the body and skin, can be activated by various forms of thermal stimuli. As a result, in hyperalgesic conditions, such as inflammatory or neuropathic pain, overstimulation of the TRPV1 receptor would be useful in deleting TRPV1 receptor-positive neurons and eradicating sensitivity to nociceptive stimuli without disrupting normal sensory transmission via fibers that do not express TRPV1 receptors.When TRPV1 receptors are continuously activated, a large and sustained increase in intracellular Ca2 + levels is induced, resulting in excitotoxicity that compromises and deletes TRPV1-expressing cells. In a previous study on the effect of Uyghur sand therapy on the dynamics of arterial flow in knee joints, a sand bath increased the inner diameter of knee arteries, sped up blood flow, and helped to increase the uniform velocity distribution. Besides. In that study, the sand bath was only applied to the knee, whereas in the current study, the Siwan sand bath was applied to the entire body, resulting in improved circulation in all body joints. Therefore, exposure to more thermal stimuli is better than less thermal stimuli, which may explain the significant changes of pain in the group received 5 days of treatment compared to those received 3 days of treatment.Decreased pain severity and increased threshold can also be attributed to the thermal effect of a sand bath on circulation, as an abnormally low level of peripheral circulation is one of the causes of pain.As expected, the reduction in pain intensity and increase in pain threshold and their beneficial effect on anxiety significantly alleviated kinesiophobia in both groups. This may be due to the pain reduction achieved, but it could also be due to the psychological support provided by the patients’ conversations. Owing to limited resources, the multidisciplinary treatment approach in Siwa is not the standard medical practice for outpatient rheumatic patients in Egypt. However, in traditional Siwan healing centers, most patients spend the night after a sand bath, getting to know each other, sharing their experiences of the disease and sand bath, and supporting one another. These friendly conversations mean a great deal to them, as most of them strongly agree with the statement, “People do not take my medical condition seriously enough” on the Tampa kinesiophobia scale. Considering that multidisciplinary treatment is favored for rheumatic pain owing to its complexity, the therapeutic milieu used to treat kinesiophobia includes interpersonal communication, such as group sessions and feedback sessions.Siwa is a very dry, hot, and distant oasis in the middle of the desert, especially during the summer months. Traditionally, patients go there seeking for a relief from pain. The treatment protocol followed depends on the healer’s experience, and it needs to be assessed and standardized. Although the current study showed significant changes in all the parameters measured in the 5-days group, exposure time cannot be considered as a variable affecting the outcomes because of the insignificant difference found between the 2 groups’ outcomes. In the current study, the clinical impact of traditional Siwan therapy cannot be reported, and it is difficult to derive causal relationships because there is no control group. which is supported by the results of group two. This strongly suggests that more repeated measures studies are needed to investigate the optimum effects of this type of therapy.Meanwhile, the nonsignificant differences in results between the groups can be attributed to the small sample size. However, Siwa is a distant place that can receive 70 patients per year. The nonsignificant differences in results might also be attributed to the short duration of the measurement because better improvement in RA patients was found 1 month after treatment,Limitation: These research findings are limited to the applied traditional Siwan therapy program followed by the traditional healers in Siwa and the measured parameters. Further research with a larger sample size, control group, and long-term effects is required. More research is needed to compare the different outcomes and treatment protocols used in this study.Despite the significant changes in central sensitization, pain severity, and pain threshold in the most painful joint after 3 and 5 days of traditional Siwan therapy, no significant difference was found between the 2 groups. All pain parameters produced favorable results after 5 days. Regarding the exposure duration of treatment and 3 and 5 days of exposure, there was no significant difference in the outcomes.The authors thank the patients who willingly participated in this study and extend their gratitude to the Siwan traditional therapy centers, Haj Sherif Senwsy Center, Haj Ahmed Mosa Center, Haj Abdelrahman Elshriak Center, Haj Setwhy Elwahy Center, Haj Ebrahim Zamour Center, Haj Omar Taqa Center, and Haj Ahmed Damdom Center for their cooperation. The authors appreciate the support provided by the Deanship of Scientific Princess Nourah bint Abdulrahman University Researchers Supporting Project number (PNURSP2023R206), Princess Nourah bint Abdulrahman University, Riyadh, Saudi Arabia.Conceptualization: Noha F. Mahmoud, Howida A. Fouda, Islam I. Omara, Nashwa M. Allam.Data curation: Islam I. Omara.Formal analysis: Howida A. Fouda, Islam I. Omara.Funding acquisition: Noha F. Mahmoud.Investigation: Noha F. Mahmoud, Howida A. Fouda, Nashwa M. Allam.Methodology: Howida A. Fouda, Nashwa M. Allam.Project administration: Howida A. Fouda.Resources: Noha F. Mahmoud, Nashwa M. Allam.Software: Islam I. Omara.Supervision: Noha F. Mahmoud.Validation: Howida A. Fouda, Nashwa M. Allam.Visualization: Nashwa M. Allam.Writing – original draft: Islam I. Omara, Nashwa M. Allam.Writing – review & editing: Noha F. Mahmoud, Howida A. Fouda, Islam I. Omara, Nashwa M. Allam.