Chronic pain remains a serious public health problem worldwide. A spinal cord stimulation (SCS) therapy called HF10 SCS uses 10-kHz high-frequency stimulation to provide pain relief without paresthesia. In this article, we describe the therapy, device, and the methods of implant and then review the safety and effectiveness data for this therapy.HF10 SCS uses a charge-balanced stimulation waveform that has been shown to be safe in both animal and human studies. Data from a multicenter, prospective clinical trial shows that the therapy provides substantial back and leg pain relief. Numerous additional reports suggest improved pain relief in other body areas and for complex pain patterns, even for patients who have previously failed other neuromodulation therapies.The clinical experience reported in this article supports the efficacy and pain relief provided by HF10 SCS therapy. Clinical studies have also concluded that HF10 SCS does not generate paresthesia nor was it necessary to provide adequate coverage for pain relief. As clinical evidence accumulates and technological innovation improves patient outcomes, neuromodulatory techniques will be sought earlier in the treatment continuum to reduce the suffering for the many with otherwise intractable chronic pain. Chronic pain remains a serious public health problem. A recent survey estimates that almost one in five (19%) adults in Europe suffer from chronic pain with almost two-thirds of chronic pain patients reporting inadequate pain control at times Spinal cord stimulation (SCS) is an accepted cost-effective treatment option for chronic pain 4–7. SCS is typically recommended after conventional medical management and/or back surgery has failed. SCS has the advantages of being reversible and less invasive than surgeries and may cause fewer issues over time than long-term pharmacological treatments, therefore causing some to call for its use earlier in the treatment continuum Nevertheless, traditional SCS therapy still has limitations. The objective of traditional SCS is to induce comfortable paresthesia, tingling sensations, that overlap the existing distribution of pain by modulating neuronal activity Some patients find SCS-induced paresthesia to be uncomfortable. Furthermore, paresthesia variability can also increase with postural changes and body movement to the point of discomfort or in other cases diminishing to subtherapeutic levels An SCS system capable of delivering stimulation frequencies up to 10 kHz has been developed . It delivers HF10™ SCS therapy, a therapy that uses proprietary waveform with stimulation frequencies up to 10 kHz. In contrast to other currently available systems that use frequencies in the range of 50 Hz, this innovation does not require or produce paresthesia to achieve clinical efficacy Since its European regulatory approval in 2010, the Senza system has been implanted in over 2,000 patients. The device is approved in Europe and Australia for the management of chronic intractable pain of the trunk and/or limbs and is currently in preapproval clinical trials in the United States. In this report, we summarize the device, the implanting and programming procedures, as well as review the available clinical safety and effectiveness data. Lastly, implications on future pain management practice are discussed. The focus of this report is to provide a descriptive summary of an approved device and an up-to-date review of the current published clinical experience, rather than to address mechanisms of action, or comparative efficacy with other treatment modalities.HF10 SCS is SCS provided at a much higher frequency than traditional SCS systems. The HF10 SCS waveform consists of a biphasic charge-balanced pulse train with pulse widths usually set to 30 μsec and a pulse rate of 10 kHz. Table Under fluoroscopic guidance, stimulation leads are placed according to anatomical landmarks. Leads are placed in the midline epidural space with a staggered offset to cover the target areas in a contiguous fashion. For back and leg pain, the first electrode of one lead is usually placed at the top of the T8 vertebra and the last electrode of the second lead placed at the bottom of the T11 vertebra with some overlap of the leads at the T9/T10 disc. For neck and arm pain, the electrodes are placed along the C2–C7 vertebrae. These positions have been determined by empirical observations to be effective. The overlap provides some protection against lead migration, which can be especially common during the trial phase. This large span is provided by SCS octopolar leads that have 5-mm spacing between the contact edges. The anatomy-based surgical placement simplifies the implant procedure compared with traditional SCS, where the physician must take time to position the leads to assure that stimulation from the electrodes covers the patient's painful areas with paresthesia. This process often referred to as “paresthesia mapping” involves changing sedation and verbally interacting with the patient to discuss perceived sensations. The physician often must physically move the leads and perform intraoperative programming with the aid of a technician to optimize paresthesia distribution and comfort. With HF10 SCS, because the physician does not need to check for paresthesia coverage, the patient is allowed to remain under sedation continuously, improving surgical workflow and increasing patient comfort. After the leads are placed, the impedances are checked to ensure the integrity of the stimulation system, and the leads are verified to be in the epidural space before completing the procedure.With HF10 SCS therapy, the patient undergoes a stimulation trial similar to traditional SCS. The leads are externalized and connected to an external trial stimulator for a period ranging from a few days to a few weeks depending on the local standard of care. Patients are provided three programs initially to evaluate which program provides the best pain relief. These programs involve multiple contacts and typically utilize amplitude between 1 and 5 mA, with amplitude gradually increased if no pain relief is experienced. A program is generally tried for a period of 24 hours and continued if successful analgesia is obtained or changed to a different program if insufficient analgesia is obtained. If none of the three programs is found to provide relief, the patient will return to the clinic for another set of programs. A permanent implantable pulse generator (IPG) is typically implanted if the trial of HF10 provided greater than 50% pain relief.Patient follow-up is similar to traditional SCS, with patients coming in every 3 months to 1 year depending on the physician's usual practice. As in traditional SCS, patients are given instructions that if their pain relief changes or additional issues arise, they should return to the clinic for evaluation and potential reprogramming or lead revision. Clinical evaluation may include assessment of new pain, and a technical assessment may include impedance testing and x-rays to determine if the leads have migrated or if some of the contacts are not functioning, similar to traditional SCS.Overall, as summarized in Table The following sections review the clinical evidence collected to date on the Senza system and HF10 SCS therapy.The Senza device has been extensively reviewed and deemed safe by regulatory agencies and has since been approved for use in Europe and Australia. This section will summarize the system's design as it relates to safety and clinical safety results.The Senza system has been designed to deliver a safe waveform—a current-controlled pulse delivered at 10,000 Hz. The waveform maintains charge balance, an important aspect of neurostimulation safety, through the use of “active charge recovery.” With the Senza system, the current is “pushed out” then “pulled in” by the electronic circuits, where both phases are actively controlled in a precise manner. Active charge recovery can allow the charge balance to happen much more quickly and controllably than “passive recharge” where the current is pushed out and is then passively recovered, as is the case with traditional low-frequency SCS therapy. Active recharge allows the stimulation frequency to reach the high rates used in HF10 SCS while still maintaining charge balance, important for safely delivering electrical pulses to the tissues.To test for safety, Butt et al. More recent safety data comes from a prospective, multicenter, open-label clinical trial at two European centers: Department of Anesthesia and Pain Management, AZ Nikolaas, St Niklaas, Belgium, and The Pain Management and Neuromodulation Centre, Guy's and St. Thomas’ Hospital, London, UK In addition to collection of adverse events, the centers performed neurologic exams at baseline and at study follow-ups. This data were reviewed by an independent panel of neurologists. No evidence of neurologic deficit or dysfunction related to the stimulation was observed.Overall, this long-term data demonstrates that the Senza system's safety profile is similar to that of traditional SCS and that when adverse events do occur, they are generally mild and reversible.The effectiveness of the Senza system can be evaluated by assessing the outcomes from two prospective multicenter studies, as well as a number of smaller patient cohorts. The most compelling results originate from patients with back and leg pain, but there are also limited data on patients with other conditions, including complex regional pain syndrome (CRPS).P < 0.001]) and back pain scores (8.12–1.88 [P < 0.001]) with HF10 SCS. The vast majority  of patients preferred HF10 SCS therapy over conventional therapy.The first clinical study of HF10 SCS was a feasibility study in 24 patients at five U.S. centers with chronic predominant back pain who were candidates for traditional SCS As just described, efficacy results are also available from a prospective, multicenter, open-label clinical trial for patients with chronic intractable back pain with 2-year follow-up conducted in Europe In this study, patients were also evaluated in subpopulations based on their clinical history P < 0.001) and a 62% reduction at 12 months (P < 0.001). Most patients (65%) had at least 50% leg pain relief at 12 months compared with baseline. Back pain was also reduced, with a 62% reduction at 12 months compared with baseline, indicating that HF10 SCS can simultaneously improve leg pain and back pain.Another post hoc subgroup analysis presented by Smet and colleagues P ≤ 0.001) from baseline to post-trial (N = 172) as well as 3.6 overall NRS reduction  from baseline to 12 months post-implant (N = 58). The NRS for back pain was collected in a subset of patients with back pain only (N = 30) and showed a reduction from 7.1 ± 1.7 at baseline to 3.3 ± 1.8 at 3 months and 3.2 ± 2.2 at 6 months (P < 0.001), with the results being similar to those published for the European study In addition to the formal clinical studies, data from four Combined, these results provide evidence that HF10 SCS therapy is able to provide effective relief for many patients with chronic back, leg, and upper body pain due to various underlying diagnoses.In addition to the larger studies, a number of single centers have confirmed that HF10 provides relief of chronic pain under real-world conditions and in a wider variety of pain conditions through retrospective data analyses.Al-Kaisy and colleagues Verrills et al. report on a cohort of chronic back pain patients who failed traditional SCS Finally, Salmon This report describes recent experience with the HF10 SCS to treat chronic pain. HF10 SCS has been shown to address pain areas that traditional SCS therapy is known to be less effective in treating, including the low back This therapy overcomes many of the known limitations of traditional SCS therapy. In particular, HF10 SCS does not require the patient to feel paresthesia, which some patients may find uncomfortable One of the most compelling aspects of this therapy is that the pain relief results obtained are at least as favorable as traditional SCS therapy  reduce the risk of overestimating the magnitude of the treatment effect It is worthwhile noting the results from a 33-patient, randomized, two-period, cross-over study on 5-kHz SCS Overall, we believe that HF10 SCS may have a significant impact on a physician's ability to treat selected patients in pain and may offer an improved patient experience with the HF10 SCS therapy.We have described an innovative approach to SCS, HF10 SCS, which uses 10-kHz high-frequency stimulation to provide pain relief without paresthesia and with more predictable procedure times. Data from multiple sources, including a multicenter, prospective, clinical trial, show that the therapy appears to provide substantial back pain relief and may provide improved pain relief in other body areas and for complex pain, even for patients who have previously failed SCS and/or PNFS. This therapy may change the way pain patients are treated with neuromodulation, potentially moving SCS to a place earlier in the treatment continuum.


We set out to assess the efficacy of radiofrequency-inducedintradiscal nucleoplasty in reducing pain in symptomaticpatients with MRI-defined lumbar disc herniation and theirsatisfaction with the procedure. We compared the patients’pain intensity and severity of disability scores before andafter undergoing the procedure in a retrospectivequestionnaire. These patients reported statisticallysignificant reduction of pain intensity and disability levelafter the procedure. We conclude that radiofrequencyinducedintradiscal nucleoplasty is an acceptable alternativeminimally invasive procedure in relieving the symptoms ofpatients with lumbar disc herniation.Radiofrequency-induced intradiscal nucleoplasty, coblationtherapy, percutaneous lumbar disc decompression,intervertebral disc herniation, low back pain Chronic low back pain is a major social, economic, andhealthcare issue. The studies evaluating chronic low backpain estimated that the average age-related prevalence ofpersistent low back pain as 12% in children and adolescents,15% in adults, and 27% in the elderlyThe mainstay of management in these patients is mostlysymptomatic palliations which include long term orintermittent analgesics, physical therapy, behavioralmanagement, and psychotherapyRadiofrequency intradiscal nucleoplasty (RIN) is aminimally invasive procedure for disc decompression thatutilizes patented coblation technology for ablating andcoagulating the intervertebral disc. This procedure uses afraction of radiofrequency energy required by traditionalradiofrequency energy systems in a process referred to ascoblation. The technology creates a low-temperature (52°C)plasma field of ionized particles that breaks down organicmolecular bonds within the tissue, creating small channels inthe disc. The result is that a small portion of the nucleuspulposus is coagulated, reducing intradiscal pressure.Subsequently, pressure on the annulus fibrosus and nerveroot is also reduced The proposed advantage of this technology is that theprocedure provides for a controlled and highly localizedablation, resulting in minimal collateral damage tosurrounding tissue. There is decreased morbidity and shorterrecovery time associated with this procedure. RIN hasbecome increasingly popular in the last three decadesbecause of its good clinical success demonstrated in properlyselected patientsThis study was undertaken in an orthopaedic clinic of aprivate hospital in Kuala Lumpur. Thirty-six patients withsymptomatic low back pain and contained lumbar discherniation confirmed with MRI who underwent RIN fromyear 2006 to 2008 were included in the study. All procedureswere performed by a single surgeon. These patientsresponded in a retrospective questionnaire  evaluating their condition before andafter treatment with RIN.Two outcome measurement tools, namely, the Oswestry LowBack Pain Disability Questionnaire (OLBPDQ) and VisualAnalogue Scale of Pain (VAS) were included in thequestionnaireThe patient’s pain score was evaluated using the VAS on anominal scale of 0 (no pain) to 10 (worst pain ever) asexperienced before and after treatment. The student paired Ttestwas used for comparison of means. Statisticalsignificance was defined as p < 0.05.Thirty six patients participated in this study. Each of themindicated their pre- and post-treatment score for the 10disability parameters in the Oswestry Low Back PainDisability Questionnaire. The mean Oswestry Disability Index(ODI) for each disability parameter is shown in Except for ‘personal care’, there was statistical significancebetween the mean ODI pre- and post-treatment (p < 0.05).Similarly, with regards to pain intensity, the patientscompleted the Visual Analogue Score for pre- and posttreatment.See  The diffOur study showed that pain intensity, lifting, walking, sitting,standing, sleeping, sex life, social life and travellingsignificantly improved after treatment with radiofrequencyinducedintradiscal nucleoplasty as measured by the ODI andVAS. Our results demonstrated the efficacy of IntradiscalNucleoplasty in improving symptoms and daily functioningof patients with disc herniation after treatment.In our study, the mean ODI post-treatment was 9.80. Aprevious study found that the mean ODI of normalpopulations was 10.1There were statistically significant differences between pretreatmentand post-treatment scores in every aspectmeasured by the ODI except in personal care (p>0.05). Thismay be due to the fact that the pre-treatment scores forpersonal care were not significantly higher compared withideal levels.Three patients in our study reported worst scores posttreatment. It was noted that these three patients hadexpanded indications. They required more aggressivemodality of therapy for their condition but they opted toundergo RIN instead, which would be suboptimal inaddressing their problem. Hence, we infer that strictadherence to the stated indications for intradiscalnucleoplasty should be advised for desired outcomeThis study has several limitations such as the relatively smallsample size, possible recall bias as well as variability in theindividual perception relating to pain intensity and disabilitylevel.Radiofrequency-induced intradiscal nucleoplasty is anacceptable minimally invasive procedure for containedlumbar disc herniation as it gives good pain relief andreduces disability. We recommend this procedure in carefullyselected patients with chronic low back pain due to lumbardisc herniation.


Dystonia is a neurological disorder characterized by intermittent or sustained muscle contractions that cause abnormal, usually repetitive, movements and postures. Dystonic movements can be tremulous and twisting and often follow a pattern. They are frequently associated with overflow muscle activation and may be triggered or worsened by voluntary action. Most voluntary muscles can be affected and, in the case of the neck muscles, the condition is referred to as cervical dystonia (CD), the most common form of dystonia. The high incidence of pain distinguishes CD from other focal dystonias and contributes significantly to patient disability and low quality of life. Different degrees of pain in the cervical region are reported by more than 60% of patients, and pain intensity is directly related to disease severity. Botulinum toxin (BoNT) is currently considered the treatment of choice for CD and can lead to an improvement in pain and dystonic symptoms in up to 90% of patients. The results for BoNT/A and BoNT/B are similar. The complex relationship between pain and dystonia has resulted in a large number of studies and more comprehensive assessments of dystonic patients. When planning the application of BoNT, pain should be a key factor in the choice of muscles and doses. In conclusion, BoNT is highly effective in controlling pain, and its analgesic effect is sustained for a long time in most CD patients. Th. Th15]. DYT1 to DYT25) have been mapped in families with pure forms of dystonia, dystonia plus other movement disorders or sporadic cases. Until the recent description of the genes CIZ1 (DYT23), ANO-3 (DYT24) and GNAL (DYT25) associated with CD families, only TOR1-A (DYT1) and THAP1 (DYT6) had been linked to isolated dystonia [DYT1 dystonia. It can be observed in the generalized form of the condition as well as in the segmental and focal forms [DYT6 dystonia phenotype is highly variable even within a single family, ranging from the absence of signs and symptoms in unaffected carriers to generalized dystonia. It tends to remain in the focal or segmental form more often than DYT1 [Over the past 20 years, several loci  ,27,28,29Onset of CD is usually insidious although in 13% of patients symptoms may start suddenly . InitialThe abnormal posture(s) in CD can be the result of any combination of the possible postures of the neck, which has many degrees of freedom because of the anatomy of the atlantoaxial joint and cervical spine, the large number of muscles and the complex origins and insertions of these muscles . The moset al. [The clinical behavior of patients with tardive dystonia has been observed to be different from that of idiopathic dystonia. In a study of the clinical characteristics of CD, Camargo et al.  found reet al. . Patientet al. .In some CD patients, sustained abnormal postures of the head may be associated with fast or slow intermittent movements and tremor. Twenty-four per cent of CD patients have neck spasms, 23% present with head jerks and 15% have both movements .Pain is the main reason for patients to seek treatment for CD ,32. WhenIn over 85% of patients, the local pain associated with CD occurred in the neck, shoulder and back ,41. RotaPain in CD correlates with disease severity, but this relationship is complex. It is not clear whether the pain contributes directly to an increase in the severity of the condition or whether it is a consequence of increased severity of the condition . The paiAlthough over 50% of CD patients complain of headache, the characteristics of this pain do not differ from those of headaches found in the general population. About 10% to 20% of CD patients have chronic daily headache, but only 1.3% of them meet the criteria of the International Headache Society for headache attributed to craniocervical dystonia ,43,44. HInternational headache society criteria for headache attributed to craniocervical dystonia :(A) Sensation of cramp, tension or pain in the neck, radiating to the back of the head or to the whole head and fulfilling criteria C and D;(B) Abnormal movements or defective posture of neck or head due to muscular hyperactivity;(C) Evidence that pain is attributed to muscular hyperactivity based on at least one of the following:(1) Demonstration of clinical signs that implicate a source of pain in the hyperactive muscle  and(2) Simultaneous onset of pain and muscular hyperactivity;(D) Pain resolves within three months after successful treatment of the causative disorder.Many orthopedic and neurological complications causing cervical and radiating pain can be observed in CD patients. Among them, premature degeneration of the spine, spondylitis, vertebral subluxation, bone fusions, bone fractures, radiculopathy and myelopathy have been reported . AlthougAn ideal rating scale should be as short and simple as possible so that it can be implemented across multicenter clinical studies as well as in daily clinical practice. Not only functional disability but also the influence of the condition on activities of daily living and the psychosocial burden imposed on patient’s well-being need to be considered .TWSTRS is the oldest tool for measuring severity, disability and pain in dystonia. It is valid, reliable and sensitive to changes in CD . The TWSThe CDQ-24 is a disease-specific QoL instrument designed to investigate problems in daily-living skills related to CD and comprises 24 items within five domains related to stigma ; emotional well-being ; pain ; activities of daily living  and social/family life . Scores for each item range from 0 to 4 in increasing order of severity of impairment . The valDay-to-day capacities and activities, pain and duration of pain, and global assessment of pain .The PNRS is a validated, single-item question on the current level of pain (range 0–10) with established cut-points of 0–3 for mild, 4–6 for moderate and 7–10 for severe. It is a widely used and recommended subject-reported measure. There are established cut-points, and the pain rating is independent of any other domain ,49,50.This questionnaire consists of eight subscales , each ranging from 0–100. It can detect improvements in pain, activities of daily living and psychological and psychosocial functioning in patients with idiopathic CD following treatment with greater sensitivity than the gold-standard, TWSTRS. It is therefore recommended as the measurement tool of choice ,49,50,51BoNT, in particular BoNT/A and BoNT/B, has been successfully used to treat many neuronal disorders by taking advantage of its ability to interfere with a wide spectrum of physiological functions, ranging from a decrease in muscle contraction to pain alleviation . BecauseBoNT is the treatment of choice for CD ,53,54,55When BoNT is injected into muscles, improvements in CD symptoms can usually be observed after one to 14 days. The peak effect typically occurs between two to six weeks after the injections, and the effect begins to wear off after 10–12 weeks. Some degree of muscle atrophy is observed after two weeks of treatment, and recovery of about 70%–80% of muscle mass occurs after three months .The muscles to be injected vary according to the type of dystonia: for torticollis, the contralateral sternocleidomastoid and ipsilateral splenius; for laterocollis, the sternocleidomastoid, splenius, trapezius and scalene; for bilateral retrocollis, the splenius and trapezius; and for bilateral anterocollis, the sternocleidomastoid . Injecti® is 500U, which results in significant benefits for most patients and minimal adverse effects [® studies show that a dose of between 100 and 300 U is effective [Pain must be taken into consideration when determining the dose and the muscles to be injected . It is u effects ,64. Botoffective .a) a reduction in tone and volume, resulting in subsequent decompression of the nerve fibers, and (b) an increase in tissue perfusion, improving muscle metabolism by increasing oxygenation and eliminating sensitization [A number of studies have been conducted since 1986 to establish the efficacy of BoNT  15,33,6,70,71,72tization . Howevertization . Furthertization ,73.et al. [® and 35 who received Dysport® using a Botox®/Dysport® dose-conversion ratio of 1:3. The average doses of Dysport® and Botox® were 477 U (240–720 U) and 152 U (70–240 U), respectively. There were no clinical or statistical differences between the two groups, and the incidence of complications was similar. Ranoux et al. [® and Dysport® using a Botox®/Dysport® dose-conversion-ratio of 1:3 and 1:4. All three treatments  were effective. There were no statistically significant differences in the results for the groups treated with Dysport® 1:3 and with Dysport® 1:4. However, patients treated with Dysport® had better outcomes than those treated with Botox® after one month of treatment. There were more adverse effects in patients receiving Dysport® although this was not statistically significant. Marchetti et al. [® and Dysport® of 2:1 to 11:1 with similar adverse effects in both preparations. Unlike other authors, Marchetti et al. stated that BoNT preparations cannot be accurately compared using a dose-conversion ratio and that clinical decisions should therefore be taken independently of dose-conversion factors, which are not accepted by consensus.While there is proof of the efficacy and safety of BoNT and its superiority over anticholinergic drugs, doubts still remain about the types and doses of toxins that are most useful in the treatment of CD. Odergren et al.  comparedx et al. , in a sti et al. , with a A comparison of BoNT/A and BoNT/B for CD was carried out in a multicenter controlled study with 139 patients. The results for pain relief and motor and disability improvements were similar for 74 patients receiving BoNT/A (maximum dose 250 U) and 65 receiving BoNT/B . There were, however, differences in the complications caused by these two types of BoNT, xerostomia and dysphagia being significantly more common in patients receiving BoNT/B . BoNT/B A major cause of treatment failure with BoNT/A is toxin resistance. Long-term BoNT use may result in the production of neutralizing antibodies, which can impair clinical efficacy. A higher dose per session and frequent injections are associated with increased risk of developing immunoresistance . TherefoDespite the extensive benefits of BoNT for CD patients, treatment cost is a major factor limiting its use. A pharmacoeconomic study with CD patients showed that the average cost of CD treatment is US$ 97 ± 29 per month, rising to US$ 228 ± 30 a month after treatment with BoNT. The increase in cost refers only to the price of BoNT injections as spending on hospital care and diagnostic procedures decreases after treatment with this neurotoxin. Furthermore, the measured costs did not include the clinical improvement and the impact of pain relief, reduced social isolation and improved emotional behavior on QoL .Physiotherapy can be combined with BoNT/A injections. There is evidence that a multimodal physiotherapy program consisting of active exercises, stretching and relaxation in addition to BoNT/A treatment induces beneficial effects on pain alleviation and disability in CD patients .BoNT/A is considered the treatment of choice for CD. It is a safe and effective form of treatment for motor symptoms and pain. When planning the application of BoNT, pain is an important factor that should be taken into consideration in the choice of muscles and doses. In addition to providing motor improvement and pain relief, BoNT/A improves patients’ QoL and social life, corroborating this choice of treatment for CD.


Pain is a common symptom in children and adolescents with JIA. It has been hypothesized that frequent pain experiences sensitize pain processing pathways, resulting in hypersensitivity to later painful stimuli. A lower pain threshold (PT) and pain tolerance in JIA patients have been demonstrated in previous studies using pressure algometry and the cold pressor task.To investigate pain thresholds in adolescents with JIA compared to age and sex matched healthy controls, using several modalities for experimental pain testing.Consecutive adolescents with JIA (16-18 years) were recruited from the pediatric rheumatology outpatient clinic at St. Olavs Hospital. Healthy controls were recruited from a local upper secondary school. Both completed a validated questionnaire on health and quality of life (SF-36), and reported pain from the last week . Quantitative sensory testing was conducted, and thermal detection pain thresholds (PTs) recorded. A thermal element was held against three specified locations of the participant’s skin, and the participant was instructed to press a button when he/she felt changes in temperature or pain. Pressure algometry was performed on two well-defined anatomical areas, giving the pressure pain threshold (PPT).Compared to 19 healthy controls, the 14 patients with JIA reported more pain during the last week, and had a less favorable score in the physical SF-36 domains, but no difference in the mental health domains. They displayed a lower PPT, but similar cold and warmth PT compared to the controls. When subdividing JIA patients with active and inactive disease, patients with inactive disease had a lower cold PT and PPT, and a tendency towards a lower heat PT compared to controls. Patients with active disease had a tendency towards higher PTs in all three modalities compared to both healthy adolescents and patients with inactive disease.Our results indicate that JIA patients may be subject to a sensitization, giving lower pain thresholds in inactive disease, but once the disease is active, painful arthritis may act as a diversion leading to increased rather than lowered PT.None declared.


Pain is one of the side effects of episiotomy. The virtual reality (VR) is a non-pharmacological method for pain relief. The purpose of this study was to determine the effect of using video glasses on pain reduction in primiparity women during episiotomy repair.This clinical trial was conducted on 30 primiparous parturient women having labor at Omolbanin Hospital  during May-July 2012. Samples during episiotomy repair were randomly divided into two equal groups. The intervention group received the usual treatment with VR  and the control group only received local infiltration (5 ml solution of lidocaine 2%). Pain was measured using the Numeric Pain Rating Scale  before, during and after the episiotomy repair. Data were analyzed using Fisher’s exact test, Chi-square, Mann-Whitney and repeated measures ANOVA tests by SPSS 11.5 software.There were statistically significant differences between the pain score during episiotomy repair in both groups (P=0.038).Virtual reality is an effective complementary non-pharmacological method to reduce pain during episiotomy repair.Trial Registration Number: IRCT138811063185N1. This technology allows the user to interact with a computer (or other devices), that simulates the reality and the pain is reduced through diverting patient’s attention from the real world. It feels as if a person has become an active participant by visual, auditory, and other senses.2Virtual Reality (VR) is a new technology3 Morris et al. in a study showed that virtual reality is significantly safe and beneficial in reducing pain.4During the past years, an effective use of virtual reality has been used to reduce pain in painful medical interventions, particularly on children, such as intravenous line insertion and even during chemotherapy in adults. Ramachandran and Rogers-Ramachandran used their first research in this area by building a virtual mirror in 1996. In 2000, Hoffman published the first valid results on this topic by using virtual reality as a method for pain relief during the burn wound dressing of two patients.5 Medio-lateral episiotomy rate in 2009 was reported at 19% of vaginal deliveries and 40.6% in primiparity.6 Vakilian et al. reported episiotomy as routine in Iran for all primiparity women.7 However, this is now limited only to special cases.8Episiotomy is a surgical procedure common in the delivery room.9 and pain relief requested by a woman is considered as a medical indication for the use of pain relief methods. Nurses and midwives are responsible for responding to the need for pain relief (if needed).10 Poor management of pain, decreases the efficacy of therapeutic intervention.11 Jahani et al. reported a negative correlation between satisfaction and pain in the second stage of labor.12 Nowadays, the interest for using non-pharmacologic methods is increased due to the non-invasive nature and no severe side effects.4 The use of VR, as a non-invasive and analgesic method without drug addiction and minimum side effects is used in clinics.2 This study aims at determining the effect of virtual reality on pain in primiparity women during episiotomy repair.Pain is one of the side effects of episiotomy,The sample size was estimated based on the results from a pilot study on 10 parturient women . The estimation led to 13 parturient women; however, the sample size was increased to16 for a higher level of confidence in each group. Of the 178 primiparous referred to the Omolbanin Hospital of Mashhad during May to July 2012, 32 eligible women fulfilled the criteria and were selected for this study (figures 1). Women in the active phase of labor (dilation 4-5 cm) were randomly assigned into two groups (16 samples in each group). This study was approved by the Committee for Human Research at Mashhad Medical University with the registration NCT01659359. Informed written consent was obtained from each participant after full debriefing about the VR equipment.The inclusion criteria were Iranian national, low risk of pregnancy without obstetric complication  in all stages of labor, spontaneous labor associated episiotomy incision, no history of mental illness, addiction, motion sickness, and headaches. The exclusion criteria were Apgar-score <7 in 1 minute and 5 minutes of birth, neonate anomaly, and receiving unusual lidocaine during episiotomy repair (higher than 5 ml lidocaine 2%). The assistant researcher or assessor was an expert midwife with over twenty years of experience in this maternity unit. Initially, the assessor was trained by the researcher on video-glasses and the research methodology. All deliveries were done by the assistant researcher in lithotomy position. After delivery, the intervention group received VR added with anesthesia  and the control group received standard anesthesia . In the VR group, prior to perineal repair, video glasses were deployed and the audio was adjusted to suit the patient. The repair method was the same in all patients and was done by the same expert midwife using a 2-0 chromic suture . The length and depth of the wound were determined by a scaled sterile swab. The pain intensity was measured based on a Numeric Pain Rating Scale (0-100) before and during the four stages of repair, namely the first minutes of infiltration anesthesia during Hyman repair, during skin repair, immediately after the repair and the first hour after the repair. Data was collected using a questionnaire  and the VR equipment. After the episiotomy repair, the time was recorded from the first suture to the last. In addition, parturient satisfaction was recorded before and after episiotomy repair. The reliability of the questionnaire was assessed using the test-retest . 4,6Validity scores for NPRS and reliability were confirmed to be 0.76 and 0.90, respectively.Demographic information was analyzed with descriptive statistics including Mann-Whitney test for comparing pain score, episiotomy characteristics and clinical data and Fisher’s exact tests for baseline characteristics , pain intensity. In addition, analysis of repeated measures ANOVA was used for pain reduction efficacy between the five conditions (before and after). The data were analyzed by the SPSS 11.5 software.VR EquipmentThe VR equipment consisted of a video player  connected to a pair of video glasses  including the connection cables and one 3D film . Video glasses include two miniature LCD viewing screens (for the right and left eyes) with 480×640 pixels resolution per display and two external headphones  weighing 85 grams. The unit included an external remote control device. Thirty-two patients were included in the study among which 30 patients were considered as eligible for data analysis. One patient was excluded due to malfunction of the remote control device (VR group) and the other patient due to delivery complication (control group).The mean age of the patients was 24.1±4.1 (18-34 years) and 60% (n=18) had secondary or higher education level. The majority of patients in both groups were homemakers . All patients were satisfied with the gender of their newborn. Mann-Whitney and Fisher’s tests did not show statistically significant differences between baseline characteristics  and clinical data such as fatigue score or cervical dilation . Both grFisher’s exact test showed no significant differences in any of the cases. The result showed significant differences on episiotomy incision depths between the intervention group and the group receiving standard care . Additionally, the same analyses were repeated with the inclusion of the duration of repair, and there was no significant difference between the groups . However, Mann-Whitney test showed patient with a VR distraction condition reported a significantly lower repair time than patients in non-VR group .The pain score at different stages of the episiotomy in both groups was analyzed and compared by repeated measures ANOVA . We obse4 reported that, approximately five samples (11 burn–injured patients) felt less severe pain during the usage of VR with analgesics condition than those in standard condition. Hoffman et al.13 found that all patients experienced significantly less pain . Wint et al. performed a pilot study on 30 cancer patients (10-19 years) and compared the efficacy of VR in puncture cerebrospinal fluid (CSF) in both VR and standard care conditions. The participants reported no significant difference in pain intensity.14To our knowledge, this is the first use of VR in a maternity ward for pain relief in parturient women. The VR system used in this study was simple  and appropriate for use in the delivery room. The results indicate that the clinical use of virtual reality (VR) with local anesthesia can reduce pain during the episiotomy repair more than those receiving standard care. These results concur with two other studies. Morris et al.13 In the study by Wint et al., the cancer patients who were adolescents at the time of lumbar puncture, previously experienced lumbar puncture. However, in our study, the patients did not have prior experience with pain perception in episiotomy since they were primigravida.Based on Gate Control Theory of pain and previous experiences; parameters such as culture, stress and psychological factors have a powerful influence on the perception of pain by a patient and it effect pain signals perceived by the brain. The intensity of pain signals, depending on the patient’s concentration can be interpreted as very painful to mild pain.15Gershon et al. compared the condition caused by VR distraction, non-VR distraction, and standard care. The patients were children and adolescents (7-19 years) with cancer. The pain intensity was evaluated at the time of catheter insertion under the skin and the pain score was evaluated after joining the needle to catheter by a nurse. They found that all patients, especially those with higher age, experienced significantly less pain (P=0.03).Researchers have observed a difference related to the attractiveness of a film played by the VR system. The tendency of a patient to focus on a film influences the level of distraction caused by the VR technology and pain severity. Therefore, personal interest and preference of a patient should be considered when deploying a VR system.In this study, similar to the study by Gershon et al., there was a wide age gap between the participants (18-34) and the patients selected one out of the five films presented to them (i.e. indicating common interest of the patients). One reason for the success of our research could be due to the appropriateness and attractiveness of the movies made available to the patients. Additional success factor was the integration of the parameter “culture” while selecting participants for this study. Note that in Gershon’s study, the patients were from different countries with different cultural backgrounds. Based on the Gate Control Theory, culture can affect pain perception. This clarifies our reasoning behind being an Iranian national as an inclusion criterion in the present study.2,16 They confirmed the efficacy of VR on intensity reduction and unpleasantness of pain in a clinical case series of 21 patients who had been hospitalized due to acute trauma (P=0.04).Patterson et al. were the first to use VR system to augment hypnosis.4Recent studies suggest that not only the virtual environment in the path of the nerve pain interpretation makes a difference, but also reduce the perceived pain by decreasing brain activity on pain.17 In other words; severe pain can obscure the beneficial effects of VR techniques.Pain severity is another factor that should be considered when using virtual environments. McCaul and Malott announced that extreme stimulus prevents the effects of VR distraction.In this study, based on NRPS, the mean of the pain score was <40. Sixty present of the non-VR group expressed severe pain during the skin repair, while the severe pain in the intervention group was 20% without statically significant difference Another interesting result from this study was a reduction in the perceived pain period during episiotomy. Patients stated that the perceived repair time was less than 46% of the actual time spent (P=0.013) (table2). 18Sharar et al. evaluated data from three studies and concluded that the combination of VR and standard analgesia reduced 20% pain intensity and 26% perceived pain period in 88 patients during post-burn physical therapy.In our study, there is a significant difference between the VR group and the non-VR group episiotomy incision depth  (P=0.042) in episiotomy repair labor, but there was not any statistically significant difference between the duration of repair in both groups. Similar to other studies, this study had certain limitations. The possibility of a single-blind design and the control of individual differences and previous experience of the patients were not possible. Virtual reality is an effective complementary non-pharmacological method to reduce pain during episiotomy repair.


The pathological mechanisms of lumbar spinal stenosis are unclear. Family doctors in the primary care setting may perform medical examinations of patients with lumbar spinal stenosis. Our aim was to use the painDETECT questionnaire to quantify the pathological mechanisms of low back pain and/or leg pain caused by lumbar spinal stenosis.p < 0.05 was considered to indicate statistical significance.We enrolled 102 patients  who had been newly diagnosed with lumbar spinal stenosis at 2 facilities. The patients’ conditions were evaluated using the painDETECT questionnaire, Numerical Rating Scale, Roland-Morris Disability Questionnaire, Japanese Orthopaedic Association Back Pain Evaluation Questionnaire, and 36-Item Short-Form Health Survey. The pathological mechanisms of low back pain and/or leg pain caused by lumbar spinal stenosis were classified based on results of the painDETECT questionnaire as nociceptive pain, neuropathic pain, or unclear type of pain (mixed pain). Statistical analyses were performed using the Kruskal–Wallis test. A value of p < 0.05) than did the other groups.The mean age of all patients in this study was 70.3 ± 2 years. The male:female distribution was 37:65 (36.3:63.7 %). In all, 72 (70.6 %) patients had chronic pain (duration of ≥3 months), and 30 (29.4 %) had subacute or acute pain (duration of <3 months). The pain was classified as nociceptive in 59 patients (57.9 %), neuropathic in 18 (17.6 %), and unclear in 25 (24.5 %). The neuropathic pain group had a significantly lower quality of life (Patients with neuropathic back and/or leg pain caused by lumbar spinal stenosis may have lower physical and/or psychological quality of life than patients with such pain caused by other mechanisms. Lumbar spinal stenosis (LSS) is the one of the most commonly encountered orthopedic disorders. Family doctors in the primary care setting may perform medical examinations of patients with LSS. Therefore, an understanding of the pathological mechanisms of LSS may be very helpful for these doctors.LSS is defined as a reduction in the area of the spinal canal, lateral canal, and/or foramina. Symptoms of LSS may occur as a result of neurovascular mechanisms –3, such We considered the pain mechanisms according to a classification that included neuropathic pain, nociceptive pain, and mixed pain , 12. NeuA recent study using the painDETECT questionnaire demonstrated that neuropathic pain was less common in patients with chronic LBP and that patients with neuropathic back and/or leg pain reported significantly more pain, disability, anxiety, depression, and reduced quality of life (QOL) than patients with nociceptive pain . The patThe ethics committees of the participating research institutions approved this study. Written informed consent was obtained from all patients prior to their participation.This cross-sectional multicenter observational study was conducted nationwide at two hospitals with their attending spinal surgeons. The recruitment period was 1.5 years (1 April 2013 to 30 September 2014).The study group included 102 consecutive patients  who were newly diagnosed with LSS at two facilities: Aizu Medical Center Fukushima Medical University and the Fukushima Prefectural Minami-Aizu Hospital. Three spinal surgeons diagnosed the patients with LSS based on magnetic resonance imaging (MRI) findings of LSS, subjective symptoms, and neurological findings. All of the patients had subjective symptoms that included leg symptoms, LSS-related neurological findings, and MRI evidence of LSS. An independent radiologist assessed the MRI scans obtained for each patient at the time of diagnosis for evidence of LSS, including central, lateral recess, and foraminal stenosis. The MRI diagnosis of LSS was based on the following findings: (1) blockage of cerebrospinal fluid and/or the disappearance of fatty tissue surrounding the foramen on T1-weighted images in the sagittal view; (2) central stenosis, lateral recess stenosis, and/or foraminal stenosis caused by lumbar disc compression from the front, and/or increased size of the ligamentum flavum, and/or articular factors from the back in the axial view; and/or (3) compression of the nerve root surrounding the foramen in the coronal view. The ankle-brachial pressure index (ABI) was also checked in all patients to distinguish NIC from vascular intermittent claudication (ABI <0.9). The ABI is the systolic pressure at the ankle divided by the systolic pressure at the arm. It has been shown to be a specific and sensitive metric for the diagnosis of peripheral arterial disease .The inclusion criteria for all patients were (1) a diagnosis of lumbar spondylosis, degenerative spondylolisthesis, or degenerative scoliosis with LSS; (2) pain and/or numbness in the lumbar dermatomal distribution; (3) motor or sensory neurological signs  in the affected dermatomes; (4) cognitive capability to satisfy our inquiries; and (5) neurogenic NIC due to LSS. The exclusion criteria for all patients were (1) diagnosis of lumbar degenerative disease without LSS; (2) predominantly axial spinal pain; (3) rheumatoid arthritis; (4) known peripheral neuropathy; (5) history of workmen’s compensation or disability issues; (6) chronic depression and use of antidepressant medication; and (7) patients with an ABI of <0.9.The painDETECT neuropathic pain screening questionnaire scores  were useNumerical rating scale (NRS) and Roland-Morris Disability Questionnaire (RDQ) scores  were useThe Japanese Orthopaedic Association Back Pain Evaluation Questionnaire (JOABPEQ) , 24 and p value of <0.05 was considered to indicate statistical significance. The statistical analyses were performed using StatView 5.0 statistical software . The statistical power analysis of this study was performed using G*Power 3.1   and in two SF-36 subscales [physical function and bodily pain (p < 0.05)] (Tables p < 0.05)], but no statistically significant differences in any of the SF-36 subscales (Tables p < 0.05), but there was a statistically significant difference in one SF-36 subscale [bodily pain (p < 0.05)]  Overall, 58 % of the 102 patients with LBP and/or leg pain caused by LSS had nociceptive pain, 18 % had neuropathic pain, and 24 % had an unclear type of pain (mixed pain) at their first medical examination. (2) NRS scores for LBP, leg pain, and leg numbness in patients with LBP and/or leg pain caused by LSS were not significantly different among the three pain groups. The RDQ score in patients with LBP and/or leg pain caused by LSS, however, was significantly lower in the neuropathic pain group than in the other groups. (3) Three JOABPEQ subscales  were significantly lower in the neuropathic pain group than in the other groups. (4) Two SF-36 subscales  were significantly lower in the neuropathic pain group than in the other groups.The statistical power analysis performed in this study indicated a required total sample size of 102, and the power was 0.95. Therefore, we believe that the power of this study was adequate.LSS may occur at different levels in the spinal canal. It may be caused by entrapment of nerve roots in the cauda equina due to hypertrophy of the osseus and soft tissue structures surrounding the lumbar spinal canal. Central canal stenosis may compress nerve roots in the cauda equina, whereas lateral recess stenosis and/or foraminal stenosis may compress nerve roots but spare the spine , 30. AltThe prevalence of neuropathic pain in the general population is unclear, although it has been reported at 3–9 % based on the results of various screening questionnaires in Europe and the United States –34. Few The NRS scores for LBP, leg pain, and leg numbness in our patients with LBP and/or leg pain caused by LSS were not significantly different among the three pain groups. However, the RDQ score, three JOABPEQ subscale scores , and two SF-36 subscale scores  were significantly lower in the neuropathic pain group than in the other groups. These data suggest that the neuropathic pain component produced significantly lower scores than its non-neuropathic pain components and reduced the patients’ physical and/or psychological QOL. Therefore, patients with neuropathic back and/or leg pain caused by LSS should be diagnosed as soon as possible after referral. A previous study  comparedFinally it is considered that the impact of this study on education, health services and research regarding primary care would suggest that it may be very important to elucidate the pathological mechanisms and the epidemiology of LSS-derived LBP and/or leg pain by classifying the patients with LSS using painDETECT in order to analyze either neuropathic pain or non-neuropathic pain, and this may be helpful to examine how to treatment for LSS-derived LBP and/or leg pain in primary care setting.The present study has some limitations that require attention. First, we studied only a small population, although we believe that the power was adequate in this study. Future studies must plan to evaluate a larger population. Second, this study had a cross-sectional design—it was not a longitudinal study. We did not evaluate therapeutic efficacy for LSS in this study. Hence, future studies should evaluate the therapeutic efficacy for each pain group caused by LSS, including conservative versus surgical therapy. Third, it was considered the lack thorough clinical and laboratory investigation in this study, since our study utilizes only questionnaires to classify the pain introduced by LSS. A clinical study with post-licensure surveillance should be implemented, ideally by setting up a database that includes all patients seeking treatment for LBP and/or leg pain caused by LSS, minimizing losses to follow-up, and using validated methods to gather clinically relevant data including demographic information, clinical features, common co-morbidities, conservative and/or surgical treatments applied to each patient, experience and training standards of the care providers applying each treatment, and each patient’s clinical evolution .It may be important to analyze the pathological mechanisms of neuropathic pain and non-neuropathic pain in patients with LBP and/or leg pain caused by LSS. Patients with neuropathic back and/or leg pain caused by LSS may experience particularly low physical and/or psychological QOL.ABI, ankle-brachial pressure index; JOABPEQ, Japanese Orthopaedic Association Back Pain Evaluation Questionnaire; LBP, low back pain; LSS, lumbar spinal stenosis; MRI, magnetic resonance imaging; NIC, neurogenic intermittent claudication; NRS, numerical rating scale; QOL, quality of life; RDQ, Roland–Morris Disability Questionnaire; SF-36, 36-Item Short-Form Health Survey


Familial amyloid polyneuropathy (FAP) is a severe hereditary disease, due to production by the liver of a genetic variant transthyretin (TTR) resulting in tissue amyloid deposits. Cardiac involvement is of major prognostic value. Diphosphonate scintigraphy has been proposed as a diagnostic tool for TTR-related cardiac amyloidosis, but there is no consensus on the optimal radiopharmaceutical. Consequently, we compared the cardiac uptake of two 99mTc-labelled tracers: diphosphono-propanedicarboxylic acid (DPD) and hydroxymethylene diphosphonate (HMDP) in patients with TTR-FAP.122 consecutive patients with TTR-FAP were prospectively included and received randomly DPD or HMDP. Acquisitions (whole-body (WB) and chest SPECT) were performed 3 hours after intravenous injection of the tracer. Quantification of myocardial uptake on WB acquisitions was performed by use of the ratio between the geometric mean of either total or average counts of a region of interest (ROI) drawn over the heart area and the WB total or average counts . Quantification on SPECT acquisitions was performed by the ratio between 3D isocount volume of interest generated over the myocardium and a standard volume in the right lung (H/L). Quantification of soft tissues uptake was performed by use of ratio between average counts of a ROI drawn over the lumbar spine and a ROI drawn over soft tissues of the lower limb (B/ST) on the WB acquisition.The DPD and HMDP groups of patients had similar age , sex , TTR mutation  and activity of the tracer . Quantitative parameters derived from whole body acquisition were significantly greater with DPD compared to HMDP  as well as H/L derived from SPECT acquisition . The uptake by soft tissues was also greater in the DPD compared to HMDP group .The present study shows that in patients with TTR FAP, the uptake of DPD in heart and other soft tissues is superior to that of HMDP. This suggests that DPD should be prioritized for initial assessment of patients suspected of cardiac involvement of TTR-related amyloidosis. Further study is required to assess whether this difference impacts the diagnostic performance and whether DPD is more accurate for the assessment of therapy response.


Context. The McGill University Health Center (MUHC) Cancer Pain Clinic offers an interdisciplinary approach to cancer pain management for patients. The core team includes a nurse clinician specialist in oncology and palliative care, a palliativist, an anaesthetist, and a radiation oncologist. This tailored approach includes pharmacological and nonpharmacological therapies offered concurrently in an interdisciplinary fashion. Objectives. Description of the interdisciplinary MUHC cancer pain approach and analysis of treatments and outcomes. Methods. A retrospective analysis of new outpatients completing two subsequent visits  was conducted. Variables included (a) symptom severity measured by the Edmonton Symptom Assessment Scale, (b) pain and disability measured with the Brief Pain Inventory, and (c) analgesic plan implementation including pharmacological and nonpharmacological therapies. Results. 71 charts were reviewed. Significant pain relief was achieved consistently at FU1 and FU2. The average pain severity decreased by 2 points between initial assessment and FU2. More than half (53%) of patients responded with a pain reduction greater than 30%. Severity of other symptoms  and disability also decreased significantly at FU2. The total consumption of opioids remained stable; however, the consumption of short acting preparations decreased by 52% whereas the prescription of nonopioid agents increased. Beyond drug management, 60% of patients received other analgesic therapies, being the most common interventional pain procedures and psychosocial approaches. Conclusion. The MUHC interdisciplinary approach to cancer pain management provides meaningful relief of pain and other cancer-related symptoms and decreases patients' disability. Cancer pain is often cited as one of the most feared complications in cancer patients  and can Justification for Interdisciplinary Approaches. The assessment and treatment of cancer pain can be challenging and require the expertise of different clinical specialties. An anesthetist-led multidisciplinary program demonstrated initial and prolonged pain relief [n relief . Similarn relief . On the n relief . InteresA partnership with anesthetists interested in the field of interventional cancer pain management has been highlighted as a key to achieve successful cancer pain control , 7. CombTo our knowledge the efficacy of interdisciplinary approaches combining nursing and different medical specialties such as palliative care, anesthesia, and radiooncology has never been reported.The MUHC Cancer Pain Clinic. The Cancer Care Mission of the MUHC serves over 1500 new cancer patients per year within the province of Quebec. Prior to the creation of the MUHC Cancer Pain Clinic (CPC), ambulatory patients with poorly controlled cancer pain were referred either to a chronic pain unit (the Alan Edwards Pain Management Unit) or to a palliative care clinic . With time, it became obvious that a closer collaboration between these two departments could lead to better management of challenging cancer pain cases. The CPC was created in 2011 with the goal of offering an interdisciplinary approach to assess and manage cancer pain. The clinical team meets three mornings a week to do new patient assessments and follow-ups and the cancer pain nurse follows up with the patients and coordinates the care via scheduled and ad hoc phone calls from Monday to Friday. The great majority of patients are referred from the department of oncology. These referrals are triaged to the CPC when pain is the most prevalent symptom. At their first visit, patients are assessed simultaneously by a palliative care physician, a nurse clinician specialist in oncology and palliative care, and an anesthesiologist specialized in interventional pain procedures. The team is completed by a radiation oncologist joining the CPC once a week. Before meeting the patient the team reviews the case to obtain details about cancer status, current symptoms, and ongoing treatment. Patients are then seen at the same time with all the specialists present in the room. Upon finishing the assessment, a brief case discussion takes place for obtaining a clinical consensus and deciding the analgesic plan. When deemed necessary, other treatments such as physiotherapy, occupational therapy, and psychosocial support are offered upon referral. Ambulatory treatment continues with frequent scheduled and ad hoc phone consultations with the cancer pain nurse to monitor initial response to treatments, evaluate new symptoms, or answer queries patients may have. At all times, treating oncologists and the cancer pain team remain in contact to update the cancer status, coordinating the care, avoiding contraindications with ongoing antineoplastic therapies, and anticipating and preventing changes in the pain severity secondary to cancer treatments. Patients are seen in clinic usually 4 weeks after initial assessment (FU1). The next assessment (FU2) is done normally within the subsequent 6 ± 2 weeks depending on the patients' response to treatments.The effectiveness of the care provided by the CPC interdisciplinary team was assessed with a program evaluation completed at the end of the first year of operation. Of 200 new patients seen in the first two years of activity, a pain relief of 2.3 points measured with the average pain item of the Brief Pain Inventory questionnaire was observed between assessment and the second follow-up (data not published). These initial positive results prompted the design of a retrospective analysis focused on the description of the treatment modalities provided and detailed analysis of patient-reported outcomes such as pain, disability, and other cancer-related symptoms.A retrospective chart review of ambulatory patients seen at the CPC between April 2013 and March 2014 was conducted. The study was approved by the institutional ethics board and conducted in accordance with good clinical practice and applicable Canadian regulatory requirements.Charts were included in the review provided that (a) patients had been assessed and then seen as follow-up at the CPC at least twice, (b) patients had completed all the clinical questionnaires provided in clinic, and (c) the medical chart included the appropriate data to complete the research questionnaire.1 and FU2). Variables recorded included demographic data (age and gender), cancer status (primary tumour and staging), and the analgesic therapy. The analgesic plan could include pharmacological treatments  and nonpharmacological approaches including interventional procedures, radiation therapy, physiotherapy, occupational therapy, and/or psychosocial counselling.Research data were collected from the medical charts at three study time points: baseline  and the two subsequent follow-ups (FU2. Pain severity was classified as mild (0–3), moderate (4–7), or severe (8–10) [Patients were asked to complete the Edmonton Symptom Assessment System (ESAS)  at everye (8–10) .2.Patients were considered responders when their pain severity, measured by ESAS-pain and BPI-worst pain diminished beyond 30% or 50% at FUAdditionally, calculation of morphine equivalent daily doses (MEDD) was done separately for short and long acting opioids  with thet-test. Independent predictors of response were assessed using multivariate logistic regression. Parameters considered as potential predictors were those showing a statistical trend (p < 0.150) in univariate analysis and the parsimonious model was derived using backwards variable selection at a p < 0.05 level.Descriptive statistics including the mean and standard deviation for continuous variables and the count and proportion for categorical variables were produced. Changes over time from baseline in pain severity and other symptoms were assessed for statistical significance using the paired-samples From a total of 186 patients seen as new patients, 71 fulfilled the inclusion criteria and were included in the analysis. Main reasons for exclusion were lack of completion of clinical questionnaires (38.6%), poorly documented analgesic plan in the chart (27.7%), patients seen only once or twice in clinic before being referred to another service (25.5%), and patients referred to the CPC only for consideration of interventional cancer pain approaches (8.2%).Data on demographics and oncological status is summarized in Pain was assessed with the first question of the ESAS questionnaire and the first four items of the BPI questionnaire. Figures 2 was 2 points on the 0–10 NRS.The absolute pain relief calculated as the raw difference of BPI average pain between BL and FU2. The percentage of patients with mild pain increased from 11% to 40% after initial treatment, showing improvement from BL.Analysis of pain severity by categories  demonstr2, using the ESAS and the BPI worst pain. The percentage of responders was more than half of the sample when the threshold was set at 30% relief. Setting a more stringent threshold of >50% pain reduction produced a lower, yet substantial percentage of more than one-third of the sample  and the most common cancer site was gastrointestinal and gynecological. Interestingly, all of them received opioid therapy during the treatment but none methadone. More than half of them (61%) received at least one nonpharmacological therapy.Thirteen patients  presented with unchanged or increased pain severity at FUThe severity of symptoms other than pain also decreased after the course of initial treatment. Reductions in the severity of all symptoms, except appetite and shortness of breath, reached statistical significance see .2 demonstrated a significant reduction in all disability ratings except for mood and normal work. A composite interference scale of the BPI as an index of clinically significant improvement was also found significantly different between BL and FU2  Pharmacological Treatment. Upon initial consultation, the most common drugs prescribed were (in descending order) short acting opioids (76.1%), long acting opioids (43.7%), acetaminophen (42.3%), and anticonvulsants (25.4%). At FU2 the proportion changed: most common were long acting opioids (59.1%) followed by short acting opioids and acetaminophen (56.3% each). Overall, the percentage of patients taking analgesics of every category increased except for short acting opioids which decreased by 20%.1 and FU2 was observed. The mean dose of long acting opioids also changed during the study yet these changes were not statistically significant.A calculation of morphine equivalent daily dose (MEDD) was performed separately for short acting and long acting opioid  excludin2 most prescribed opioids were controlled release preparations.The comparison between short and long acting opioids revealed a change in consumption patterns throughout the study. At baseline, patients were essentially taking the same amount of short and long acting formulations whereas at FU1 13 patients (18.3%) were receiving methadone with a further increase to 17 patients at FU2 (23.9%).Ten patients (14.1%) were taking methadone for pain relief during their first assessment. These patients were normally referred to the CPC after initial consultation with supportive and palliative care department during a recent hospitalization. Upon discharge, these patients were scheduled to be followed at CPC for further cancer pain treatment. At FU(b) Nonpharmacological Analgesic Therapies. 57% of patients received at least one of the five nonpharmacological analgesic options  of achieving 30% improvement in ESAS pain, while use of radiotherapy was a significant predictor of poor outcome for 50% improvement in ESAS pain . No significant predictors of 50% improvement in BPI worst pain were identified. Correlation analysis to identify predictors of response to the treatment is presented in The cancer pain approach described in this study adopted the multidisciplinary team work as a model, taking it one step further by having multiple pain specialists simultaneously interacting with the patient. This is the foundation of an interdisciplinary approach, defined as “a synthesis of two or more disciplines, establishing a new level of disclosure and integration of knowledge” . The logA significant reduction in pain severity was consistently reported across the two follow-up visits. This difference not only reached statistical significance but can be considered clinically meaningful .A responder was the patient presenting with at least 30% reduction of pain. This threshold is considered clinically meaningful in other pain trials , yet a 3Other cancer-related symptoms decreased as well after the initial course of treatment but did not reach statistical significance in the case of appetite and shortness of breath. This may be explained by the fact that we did not use the last version of the ESAS, the ESAS revised . This ve2. This reduction was statistically significant for most but not all items. Changes in mood, normal work, and enjoyment of life did not reach statistical significance. If a two-point difference or a 30% reduction is selected as a minimum for clinically important difference [2 can be interpreted as improvement in quality of life despite the presence of advanced cancer disease.Pain-related disability decreased at FUfference , well-befference . The sig2 compared with their initial baseline intake.Study patients received opioid and nonopioid analgesic medications. The use of coadjuvants has been clearly recommended in the management of cancer pain . In the Several factors have been identified in the literature as predictors of pain relief in cancer patients. These include improvement in concomitant depression, higher socioeconomic status, and fewer comorbid conditions. Patients with severe pain at baseline and with recurrent or progressive cancer disease were less likely to experience pain improvement . In an eIt is possible that additional factors may be significantly associated with cancer pain relief; however they may have not been able to be identified due to the low sample size of our study. Additional studies with larger sample sizes are required to extensively characterize the predictors of cancer pain relief.Less than half of new patients seen during one year did not fulfill the inclusion criteria. Most of these patients did not complete the clinical questionnaires or the analgesic plan was not fully clear from the medical chart. The second main reason for not including these patients in the analysis was that they were not seen at least three consecutive times at the CPC. This is a frequent occurrence in our CPC since our patient population presents with advanced cancer disease associating important morbidity. It is our clinical routine to transfer the case to the supportive and palliative care day hospital when the disease burden becomes too important. Other limitations of the current study are inherent to the retrospective chart review design, including concerns with regard to the internal validity of the findings due to the potential incompleteness of the information collected and the lack of a comparator group. Creating such a control group within our McGill University Health Centre has become challenging since the CPC has become the main ambulatory unit treating cancer pain patients, making it unlikely to find another group of advanced cancer pain patients being treated with a different approach.The MUHC interdisciplinary approach to assess and manage cancer pain provides effective relief of pain and other cancer-related symptoms, associated with a reduction of functional impairment and an improvement of symptom burden. This approach combines pharmacological and nonpharmacological analgesic therapies along with patient-centered care to provide personalised treatment for each case. Further prospective trials are warranted to provide stronger evidence of this approach.


Pressure ulcers are costly to the healthcare provider and can have a major impact on patient’s quality of life. One of the most distressing symptoms reported is pain. There is very little published data on the prevalence and details of pain experienced by patients with pressure ulcers, particularly in community populations. The study was conducted in two community NHS sites in the North of England.The aim was to estimate the prevalence of pressure area related pain within a community population. We also explored the type and severity of the pain and its association with pressure ulcer classification. A cross-sectional survey was performed of community nurses caseloads to identify adult patients with pressure ulcers and associated pain. Consenting patients then had a full pain assessment and verification of pressure ulcer grade.A total of 287 patients were identified with pressure ulcers (0.51 per 1000 adult population). Of the 176 patients who were asked, 133 (75.6%) reported pain. 37 patients consented to a detailed pain assessment. Painful pressure ulcers of all grades and on nearly all body sites were identified. Pain intensity was not related to number or severity of pressure ulcer. Both inflammatory and neuropathic pain were reported at all body sites however the proportion of neuropathic pain was greater in pressure ulcers on lower limbs.This study has identified the extent and type of pain suffered by community patients with pressure ulcers and indicates the need for systematic and regular pain assessment and treatment. A pressure ulcer (PU) is described as a “localised injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear. A number of contributing or confounding factors are also associated with pressure ulcers; the significance of these factors is yet to be elucidated” .PUs are categorised according to the level of tissue damage. Although many different grading scales exist, an international classification was published in 2009  and inclSystematic review evidence indicates that pressure ulcers result in significant suffering and morbidity to patients . They arThe impacts of PUs on patients include pain, depression, local infection, osteomyelitis, anaemia, sepsis, gangrene and death . In a syExperience of local pain or discomfort at a potential PU body site may also be a precursor to pressure damage and patients have reported that in their view it was a precursor to PU development . A numbeReviews of the epidemiological literature carried out by Girouard et al. 2008 and Pieper et al.  identifyIn summary, qualitative evidence identifies pain as an important issue for patients preceding PU development and in PU management. Previous epidemiological research has focused on patients with existing PUs and a limitation of the literature is the lack of evidence relating to the extent of pain preceding PU development, the extent of pain associated with Category 1 PUs  and the type of pain (i.e. inflammatory or neuropathic). This study aims to determine the extent of the problem in community populations.There is a need to develop methods to assess localised pain in pressure areas, including intact skin and Category 1. In order to describe pain in patient populations with and without PUs four definitions were defined as follows:1. Pressure area: a body site where PUs commonly develop e.g. sacrum, heels2. Pressure area related pain: pain on a pressure area (see 1)3. Pressure ulcer related pain: pain on a body site with an observable PUUnattributed pressure area related pain: pain reported by the patient to be due to pressure on a pressure area (see 1) but exact body site not specified.4. unattributed pressure area related pain prevalence of 16.3% which included a 12.6% unattributed pressure area related pain prevalence in patients with no PUs and a 42.9% unattributed pressure area related pain prevalence in patients with PUs in hospital populations. It is not known whether the prevalence of pressure area related and PU pain is similar in long term care settings such as patients’ homes and care homes.A study by Briggs et al.  reportedThe current study investigates the prevalence of PU pain in community populations. Hospital populations are more accessible; the previous study  used detThis study is part of a suite of 6 studies which comprise the Pressure UlceR Programme of ReSEarch (PURPOSE), funded by the National Institute for Health Research  which aims to reduce the impact of PUs on patients through improved risk assessment and the development of measures to capture patient reported outcomes.The primary aim of this study was to● To estimate the prevalence of PU related pain within a community populationThe secondary objectives were● To assess type and severity of PU pain● To explore the association between pain and PU classificationWe undertook a cross sectional study in 2 community NHS Sites in the north of England to establish PU pain prevalence. Site 1 has a population of 259,536 of people living in urban areas  with the1. Do you currently have any pain, soreness, or discomfort, either all the time or on and off in any areas exposed to pressure ?2. Do you think your pain, soreness, or discomfort is related to either your PU or pressure/rubbing due to being in bed/chair?These questions were adapted from the case screening questions used in a large postal survey of pain prevalence in the UK .Where pain was identified, consenting patients had a detailed pain and skin assessment including pain severity, type and Grade of PU by the Clinical Research Nurse.Patients over 18 years old and on community nursing caseloads were eligible to be asked the two pain questions when they had a PU assessed as a Grade 1,2,3,4 or Unstagable  and wereThe Clinical Research Nurses were trained in study procedures including pain assessment and skin assessments by the Clinical Co-ordinator (LW) and the site Tissue Viability Nurse Specialist. No formal inter-rater reliability assessment was undertaken since previous research has demonstrated high levels of agreement between specialist nurses and clinical research nurses in skin assessment and PU classification .Standard community practice for the PU prevalence audit was used to assess and record data to ensure data capture for the total population. The two sites applied different eligibility criteria for PU case finding. Site 1 assessed all patients on the community nursing caseload, patients in residential homes, rehabilitation units, specialist palliative care units and all nursing homes in the locality. Patients in site 1 were assessed whether they were known to have a pressure ulcer or not. Site 2 assessed only patients on the community nursing caseload in the locality who were known to have an existing PU. Anonymised individual patient data were recorded by community nurses who were trained in the data collection process. Data recorded included location, date of birth, gender, height, weight, mobility, risk assessment scale  and PU classification by skin site using the EPUAP classifications . UnstagaThe original (1998) EPUAP classification was used as this was usual clinical practice in both community sites at the time of the routine PU audits.Where patients were assessed as unsuitable for the pain screening question this was recorded along with the reasons for ineligibility  and the most painful site located on a limb  as reported by the patient. Skin assessments undertaken by the community nurse for the PU prevalence audit were verified through nursing records or clinical assessment by the research nurse.All data returned to the Clinical Trials Research Unit for data processing was anonymous.Data were entered into a MACRO database; range and consistency data checks were carried out to assess accuracy of the data. Descriptive statistics were produced, no inferential statistical testing were planned or undertaken. Percentages were calculated using the total number of patients from the relevant population as the denominator . All analyses were carried out using SAS software. All percentages were rounded to 1 decimal place. Means, medians, standard deviations and ranges were summarised to one more decimal place than the data collected. The prevalence of pressure ulceration in the population was calculated as a percentage as was the overall proportion of patients reporting localised PU pain.The study was approved by the Leeds West Research Ethics Committee (REC) prior to data collection.Site 1 collected data between 8th February and 2nd April 2010 and Site 2 between 12th April and 7th May 2010. Figure The two community NHS Trusts identified 287 patients with Grade 1-4/Unstagable pressure damage. The case finding methods resulted in differing prevalence rates. In site 1, 1680 patients were assessed and of these 185 patients were assessed as having a pressure ulcer Grade ≥1, a prevalence rate of 0.77 per 1000 (185/240038)*1000 adults). In Site 2 102 patients were identified from the community nursing caseloads and assessed as having a Grade ≥1 pressure ulcer, a prevalence rate of 0.40 per 1000 ((102/251891)*1000 adults).The mean age of patients with pressure ulcers was 77.8 years  with just over a third men 34.8% (100/287), 84.3% (242/287) were assessed as ‘at risk’ on either the Waterlow Score or Braden Scale and only 1.4% (4/287) were non Caucasian . Approximately a third of PUs  were Grade 1, 40.2% (177/440) were Grade 2 and 24.5% (108/440) were severe PUs.Two hundred and eighty seven patients with PUs were identified and of these 176 (61.3%) were asked the pain screening questions; Figure Demographic details for the three populations  are given in Table unattributed pressure area related pain, 96 were not able or declined to participate in the full pain assessment  of the population reporting pain.Of the 133 patients with The mean age of these 37 patients was 72.6 years , most (70.3%) patients were assessed in their own homes, the remainder were assessed in residential or nursing homes, rehabilitation or palliative care units. Twenty eight patients (75.7%) were female and all were white British ethnic origin  skin sites . No pressure area related pain was reported on normal skin, whilst patients reported PU pain for 98.1% (n = 53/54) of all PUs  reported ulations ,32.The detailed pain assessment of community patients identified pressure area related pain on all Grades of ulcer. The distribution of pain intensity measured using a 0–10 nominal rating scale was similar for all grades, which is consistent with pain intensity in other disease states, where the severity of illness is not necessarily related to patients’ reports of pain intensity . It is nIn the community setting neuropathic pain was dominant (54.5% torso and 61.1% limb). The proportion of neuropathic pain observed is similar to the prevalence of neuropathic pain in community leg ulcer patients (43.5%) , but greunattributed pain are that: skin assessment data was recorded by clinical staff which has inherent limitations [Limitations with the overall pain prevalence estimate of itations ,29,33 anThe literature review by Peiper et al.  did not For the 37 patients whose severity of pressure damage was confirmed by the Clinical research Nurse, all but one was experiencing pain related to each of their ulcers. Pain associated with PUs is also described in similar studies of PUs in acute settings identifying 59% pain prevalence , with 80The non-validated data suggests that pain occurs with every grade of PU and that pain and no pain are broadly comparable in terms of proportions at each grade. It suggests that not all Grade 4 PUs are painful whereas grade 1 can be painful. There does not appear to be an association between the number of PUs and pain.The detailed pain assessments identified that all but one pressure ulcer was painful. This is inconsistent with the unverified data. Explanations for this could be that those who do not report pain may have sensory impairment e.g. spinal cord injury or have sufficient analgesia to mask any pressure ulcer pain. It may be also be due to the small sample size.The greater proportion of reports of neuropathic compared to inflammatory pain in the lower limbs may be worthy of further exploration. The mechanisms for neuropathic pain are not yet fully understood; it is considered to be a heterogeneous group of conditions that differ not only in aetiology but also location. A review by Jensen et al.  states tA limitation of this study is the small number of patients who consented to the full pain and PU assessment. The data in Table Figure The ability to feel pain and the levels of analgesia were not reported in this study. Reporting both these variables can be subjective, particularly in community settings where access to medical records and prescriptions is difficult. Levels of analgesia can be taken from patient accounts, nursing records or observation of medications in the home however it is likely that the actual medication taken and the level of analgesia achieved vary in individual patients. The ability to feel pain is also dependent on co-morbidities e.g. spinal injury, stroke or diabetes, again records of these may not be reliable in the patients home. This study aimed to explore the association between PUs and pain, the results suggest an association in this sample of patients and it has provided useful baseline data to inform future work.The findings of this study have clinical relevance for community nurses staff. It is likely that those patients who have PUs will also be experiencing some degree of pain, this needs to be recognised, assessed and management plans implemented. It has been reported that pain can restrict movement  which maThis is the first study to report the prevalence of pain associated with PUs in a UK community population, this was found to be 75.6%. Of the patients who consented to a detailed assessment of their PU and associated pain, all reported pain at a PU site. In this small sample, areas of the body with no pressure damage were found not to be painful. Pain intensity was not related to number or severity of ulcers. Both inflammatory and neuropathic pain was identified in both limb and torso PUs, but neuropathic pain was dominant. This study has contributed to knowledge of pressure ulceration in community patients; it will inform future studies. The identification of pain, particularly in the early stages of PU development may be a valuable clinical predictor of further pressure damage.This article presents independent research commissioned by the National Institute for Health Research (NIHR) under its programme Grants for Applied research funding scheme (RP-PG-0407-10056). The views expressed in this (article/poster/presentation etc.) are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health.The authors declare they have no competing interests.JN, JB, EAN, MB, EM conceived of the study. EM, MB, MC, LW, CD, JB, SC, NS, RS, EAN and JN have made substantial contributions to the design, acquisition of data and interpretation of data. MC conducted the analysis. EM and JN drafted the manuscript and MB, MC, LW, CD, SC, NS, RS, JB and EAN have been involved in revising it critically for important intellectual content. All authors have given final approval for the version to be published. All read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1472-6955/13/16/prepub


Introduction. Radicular low back pain is one of the most common medical problems. The aim of this study was to evaluate the diagnostic accuracy of MRI and electrodiagnosis in lower extremity radicular pain in relation to history and clinical findings. Methods. In this cross-sectional study, we studied 165 sciatalgic subjects. A comprehensive history and physical examinations were taken from the subjects and recorded, and then MRI scanning and electrodiagnostic (nerve conduction velocity and electromyography) tests were performed. Results. From 152 subjects who remained in the study, 67 cases (44.1%) had radicular pain in left lower limb, 46 (30.3%) in right, and 39 (25.6%) in both lower limbs. 104 cases (68.4%) had shown some type of abnormalities in both MRI and electrodiagnosis, 30 (19.7%) had shown this abnormality only in MRI, and 21 (13.8%) only in electrodiagnosis, while 10 cases (6.5%) had both normal MRI and electrodiagnostic studies. Coordination rates of MRI and electrodiagnosis with clinical findings were 58.6% and 89.5%, respectively. Conclusion. In many MRI negative but symptomatic subjects, electrodiagnosis has an important diagnostic value. Radicular low back pain is one of the most common medical problems that cause decreased work competence and a heavy cost. Accurate diagnosis of this radicular pain has a paramount important role in proper treatment planning . HistoryThe use of imaging techniques such as magnetic resonance imaging (MRI) is indicated in the patients with atypical or refractory complains to confirm the clinical diagnosis or help to select the proper approach if surgery is necessary .Despite the accuracy of the history, physical examination and MRI in the lower extremity radicular pain, in some cases for more accurate diagnosis, other diagnostic measures are also needed. Although MRI has sufficient accuracy in the diagnosis of some nondiscogenic sciaticas such as spinal tumors, epidural varicosis, and infectious spinal stenosis, it is incapable of diagnosis in many far out  spinal stenosis lesions. Electrodiagnostic tests can especially provide useful information about the exact location of the nerve damage .Among all the electrodiagnostic studies, electromyography (EMG) technique has a very high accuracy and specificity in the diagnosis of nerve root pathologies such as denervation and dysfunction –8. There is little research comparing the accuracy of MRI with electrodiagnostic methods in the diagnosis of lower extremity radicular pain; therefore, the aim of this study was to do this in relation to history and clinical findings.At first, 165 patients with sciatica (±accompanying LBP) participated in the study. These subjects have been referred to our orthopedic department from November 2008 to December 2011. Our inclusion criteria were sciatica >6 weeks, age >15 years, and assignment of the informed consent, while we excluded those cases with a history of lumbar spine surgery, previous trauma, presence of associated disease , underlying malignancy or autoimmune disease, and those patients that medically have contraindications for MRI or electrophysiologic studies. Eventually, 13 cases were excluded due to the exclusion criteria. The remaining 152 patients, 96 patients (63.2%) were males and the rest  females. The mean age of the patients was 43 ± 5.8 (range from 22 to 73 years).t-tests.After a complete explanation of the project was given to the patients, they signed the informed consents. Demographic individual profile was recorded in a checklist. The history obtained from patients was about the nature of pain, period of pain, patient's occupation, and other symptoms that all were recorded in the individual checklist. Clinical examination included complete neurological evaluation was also recorded. All the patients had lumbosacral X-ray and MRI scanning that both were reported by an experienced radiologist. For electrodiagnostic study including both EMG and NCV, the patients were also referred to one expert physiatrist. For motor study, tibial, peroneal, and femoral nerves were evaluated while for sensory study, sural, saphenus, superficial peroneal, lateral, and posterior cutaneous nerves of thigh were checked. When the nerve root irritation was founded in both MRI and electrodiagnostic test, there was a concordance between MRI and electrodiagnostic findings. After collection of data forms, positive findings between clinics and paraclinics were compared and analyzed by software package for statistical analysis , Chi-square, and independent 67 cases 44.1%) had radicular pain in left lower limb, 46 (30.3%) in right, and 39 25.6%) in both lower limbs. Clinical and paraclinical findings in our patients were shown in Tables % had rad5.6% in bWhen the history and physical examination are taken into account, clinical accuracy of our paraclinical studies in lower extremity radicular pain is as shown in Our study compared MRI with electrodiagnosis and showed a high positive likelihood ratio for MRI, and therefore this method is considered a better modality to confirm the disease, while negative likelihood ratio for electrodiagnosis was high, or this method is a better one to roll out the disease. The high specificity of electrodiagnostic findings also has a clinical significance. Disc herniation in MRI scanning of the asymptomatic patients is a very common finding and therefore decision for surgery based on only MRI findings is not justified .As our study showed in the patients with lower extremity radicular pain the high concordance of electrodiagnosis with final clinical diagnosis (89.5% relative to 58.6% in MRI scanning) indicated the high accuracy of this modality in these patients. In this study, we found that MRI has a less accuracy and more false positive in patients with canal stenosis and the use of electrodiagnosis is very effective especially in cases with multilevel canal stenosis to determine the location of pain. Our results supported the consequences of the study conducted by Johnsson et al. . As CostThere is not a gold standard method in the diagnosis of lower extremity radicular pain, and especially in deciding to select between surgical and nonsurgical planning, other methods in addition to history and physical examination are sometimes needed. Although, MRI scanning is a very popular method used to confirm the clinical diagnosis of radicular limb pain, in some cases, it is not suffice to decide the proper treatment planning .In a study conducted by Pfirrman et al. (2004), they showed that MRI scanning has high accuracy in the diagnosis of discogenic radicular pain, but it is less accurate in the cases with nondiscogenic sciatica . Patel aOur study showed that the accuracy of MRI scanning in the diagnosis of radicular limb pain (except in discogenic sciatica) is limited and to achieve a definitive diagnosis and treatment planning, other diagnostic methods are sometimes needed. Grover in a review confirmed this result . In theiAlthough electrodiagnostic studies are not used as a routine procedure in diagnosis of lower extremity radiculopathies, they may be useful as a diagnostic aid in certain cases. These studies are useful in determining the relatively exact location and extent of nerve root involvement and they may be especially helpful in selecting appropriate treatment planning in MRI negative patients . Clinically, neuropathic pain is sometimes too similar to the sciatic pain. To differentiate between the two, electrophysiologic study is very helpful . Chiodo In conclusion, although electrodiagnosis is not used as a routine and standard procedure in the diagnosis of lower extremity radiculopathy, in many MRI negative but symptomatic patients, this modality has an important diagnostic value.