Sense of Coherence (SOC) is a measure of an individual’s capacity to use various coping mechanisms and resources when faced with a stressor. Chronic pain is one of the most prevalent and disabling conditions in clinical practice. This study examines the extent to which a strong SOC is associated with less pain and better health related quality of life (HRQoL) among patients with chronic pain.We analyzed data from the Stepped Care to Optimize Pain care Effectiveness (SCOPE) trial which enrolled 250 patients with persistent (3 months or longer) musculoskeletal pain who were receiving care in an United States Department of Veterans Affairs (VA) primary care clinic. The abbreviated three-item SOC scale was used to measure personal coping capability. Participants were categorized into Strong SOC (score 0–1) and Weak SOC (score 2–6). The Brief Pain Inventory (BPI) was used to assess the severity and disability associated with pain. Additionally, pain self-efficacy (ASES) and catastrophizing (CSQ) were assessed. HRQoL was assessed with the 36-item Short-Form Health Survey (SF-36) social functioning, vitality, and general health subscales. Multiple linear regression models were performed to examine whether SOC was independently associated with pain-specific and HRQoL outcomes, after adjusting for sociodemographic and socioeconomic characteristics, medical comorbidities and major depression.Of the 250 study patients, 61% had a strong SOC whereas 39% had a weak SOC. Multivariable linear regression analysis showed that a strong SOC was significantly associated with better general health, vitality, social functioning and pain self-efficacy as well as less pain catastrophizing. These significant findings were partially attenuated, but remained statistically significant, after controlling for major depression. SOC was not significantly associated with pain severity or pain disability.A strong SOC is associated with better HRQoL and self-efficacy as well as less catastrophizing in patients with chronic pain. SOC may be an important coping mechanism (strategy) for patients with chronic musculoskeletal pain.NCT00926588.Clinicaltrials.gov Identifier:  Musculoskeletal pain is the most common, frequently occurring, disabling and costly of all pain complaints in the primary care setting . Nearly salutogenic orientation. This orientation views the presence of stressors as not an abnormality but rather a pervasive condition for individuals [Central to understanding HRQoL and functional status is the fact that certain social factors may maintain health and prevent adverse health consequences. Antonovsky  categoriividuals . Antonovividuals , postulaividuals . In thisividuals . SOC hasividuals . As withividuals . The SOCividuals .According to Antonovsky , individDespite the potential benefits of SOC, there have been few studies examining the effects of SOC in patients with chronic pain, including its association with HRQoL and functional status. In an observational study of Norwegian patients with various musculoskeletal pain conditions referred from primary care physicians to a Physical Medicine and Rehabilitation unit, Anke et al.  found thThe aim of the present study was to determine if SOC is independently associated with pain and HRQoL outcomes in patients with chronic pain. More specifically, we postulated that a strong SOC is positively associated with better pain-specific as well as general HRQoL outcomes. Since some researchers have challenged whether SOC is truly a distinct salutogenic construct, but rather an inverse measure of persistent depressive symptoms , we alsoStepped Care to Optimize Pain care Effectiveness (SCOPE) study, which is described in detail elsewhere. This RCT was carried out in accordance with the Code of Ethics of the World Medical Association (Declaration of Helsinki) [musculoskeletal defined as regional  or more generalized ; (2) at least moderate to severe in intensity . Individuals were excluded if they (a) had a pending pain-related VA or Social Security disability claim; (b) did not speak English; (c) had moderately severe cognitive impairment; (d) had schizophrenia, bipolar disorder, or other psychosis; (e) were actively suicidal; (f) had current illicit drug use; or (g) had an anticipated life expectancy of less than 12 months.This paper draws upon data from a randomized clinical effectiveness trial referred to as the elsinki) . This stast week ; and (3)Physicians who worked in the five primary care clinics were informed of the study and asked if their patients could be contacted for potential participation in the study. For physicians who agreed, their patients who had electronic medical record evidence of a primary care visit in the past 12 months and an International Classification of Diseases (ICD-9) diagnosis of musculoskeletal pain were sent a letter describing details of the study, along with a form that could be returned expressing potential interest in study participation. A flow chart detailing screening, eligibility determination and enrollment has been previously published . More siBrief Pain Inventory (BPI) consists of two scales that measure pain intensity and pain-related functional impairment  [Arthritis Self-Efficacy Scale (ASES) measures one’s beliefs regarding the ability to manage pain symptoms [Three measures were used to assess pain-specific outcomes. The otional) -24. The symptoms . Each ofThe 6-item catastrophizing subscale of the Coping Strategies Questionnaire (CSQ) was employed to measure pain catastrophizing cognitions  ,27. StudHRQoL was assessed with three subscales of the 36-item Short-Form Health Survey (SF-36): general health, vitality, and social functioning . Each SFcomprehensibility); 2) “Do you usually see a solution to problems and difficulties that other people find hopeless?” (management); and 3) “Do you usually feel that your daily life is a source of personal satisfaction?” (meaningfulness). Study participant responses were “yes, usually” (scored 0); “yes, sometimes” (scored 1); and “no” (scored 2). Following reverse scoring for comprehensibility, all items were summed to provide a total SOC scale score in the range of 0–6; a higher score represents a weaker SOC (Cronbach’s α = .58). Following previous research [We used an abbreviated 3-item version of the SOC scale  which asresearch , SOC wasThe following demographic variables were collected by self-report at baseline and used in the present analyses as covariates: 1) age (in years); 2) sex; 3) race (white vs. black/other); and 4) medical comorbidity index  . The socStep 1 adjusted for patient age, sex, race, socioeconomic disadvantage index, and medical comorbidity. Step 2 adjusted for the same variables as in Step 1 plus the presence or absence of major depression. All analyses were conducted using SAS version 9.3 . Analyses of the measures were performed based on an intention-to-treat strategy. Group differences in the outcome total scores were estimated using mixed effects model repeated measures analysis. Missing data was minimal because the assessments were interviewer-administered. Also, follow-up interviews were completed in 98% of participants at 3 months and 95% at 12 months.SOC was defined as a binary variable (strong vs. weak SOC) and was analyzed as the main predictor in all analyses. First, univariate associations with pain-specific and HRQoL domains were evaluated by comparing these domains between strong and weak SOC patients. Next, multiple linear regression models were fitted to test the independent association of SOC with each of the 7 pain-specific and HRQoL domains as dependent variables. For each domain, two models were fitted. Of the 250 study participants, 61% (n = 152) had a strong SOC  and 39% (n = 98) had a weak SOC . The proportion of participants with a score of 0, 1, 2, 3, 4, and 5–6 was 34.4%, 26.4%, 19.2%, 9.2%, 6.4%, and 4.4%, respectively. The study participants had a mean age of 55.1 years ; 82.8% were men, 76.8% were white. The mean BPI severity score was 5.1 (SD = 1.7), and the mean BPI interference score was 5.3 (SD = 2.2). The mean number of comorbid medical diseases was 2.2 (SD = 1.3), and 24% of participants had major depression. The duration of chronic pain was 3–12 months in 2.0% (n = 5) patients, 1–5 years in 26.4% (n = 66), 6–10 years in 19.2% (n = 48), and more than 10 years in 52.4% (n = 131).Table Patients with a strong SOC were much less likely to have major depression, had fewer comorbid medical conditions, and had better educational, employment and income status. No association was observed between SOC and patient age, gender, or race.Table A strong SOC was associated with relatively large increases in the scores on all three SF-36 HRQoL domains and in the SF-12 mental MCS; including an 11.1 point increase in general health, a 14.8 point increase in vitality, a 20.6 point increase in social functioning, and a 12.1 point increase in mental health. These increases remained moderate in magnitude  and statistically significant, even after adjusting for the presence of major depression.strong SOC with outcomes was closest to that of absence of major depression for vitality (ratio of t-scores = 3.98/4.94 or 81%), followed by SF-12 MCS (67%), general health (65%), social functioning (52%), and pain self-efficacy (40%).The last column in Table Longitudinal analyses indicated that SOC did not change over the 12 months of the trial. For the intervention group, the mean SOC values essentially remained the same at baseline, 3-months and at 12-months . Similarly, the mean values changes very little in the control group at baseline, 3-months, and at 12-months . The differences between these groups were not significant. The strong associations of SOC with pain and HRQoL outcomes present at baseline persisted at 3 and 12 months. Moreover, the HRQoL outcomes did not significantly change over the 12 months (results not shown).Our study has several important findings. First, a strong SOC is associated with better pain-specific outcomes, especially for constructs relevant to coping such as better pain self-efficacy and less pain catastrophizing. Second, a strong SOC is also associated with better HRQoL, specifically self-reported general health, vitality, and social functioning. Third, the association of SOC remained significant for most outcomes (except pain intensity and impairment) even after controlling for important covariates, including the presence of major depression. Indeed, the strength of association of SOC with pain coping and HRQoL outcomes was 40-80% that of major depression. Fourth, SOC did not change over the 12 months of the trial, indicating that SOC was a stable trait in our study population.Our findings are consistent with previous studies that have found an association between SOC and HRQoL. A systematic review published in 2007 found that a stronger SOC was associated with better HRQoL . Our resSimilar to our study, a cross-sectional study of 232 participants recruited from a “Neck and Back” unit in Norway found that stronger SOC was associated with greater pain self-efficacy . Prior sAlthough low SOC does not inherently imply a depressive mood, it has been associated with depression in prior research . In contBecause of the strong association between SOC and depression, some researchers have even questioned the extent to which they are conceptually distinct from one another ,43. For Similar to Antonovsky’ s original tenet of SOC, we found that SOC was a stable trait in the present study. Many of the outcomes , changed very little over the 12 months. Therefore, we are unable to conclude that baseline SOC is not a predictor of change in HRQoL outcomes, mainly because SOC and these HRQoL outcomes remained stable over time. This lack of change over time was not surprising since the intervention did not specifically target these outcomes. According to Antonovsky ,9, SOC rThis study has several limitations. First, our sample was comprised entirely of US Veterans who received primary care from a single VAMC. Thus, our findings may be less generalizable to non-VA settings. However, in comparison to past studies with veterans, our sample included more women (18%) as well as higher educational attainment, employment rates and income. Second, there is the potential for selection bias because this study included only patients who were willing to enroll in a clinical trial. Third, the Cronbach’s α for the 3-item measure of SOC in the present study was .58, a value that is less than ideal. However, a systematic review of studies using the SOC-3 found that the Cronbach’s α ranged from .35 to .61 . SchumanKnowledge of the role of SOC in adapting to and coping with stress may equip health professionals for developing patient-centered care that incorporate SOC concepts to assist individuals suffering from musculoskeletal pain. Intervention strategies might be developed to help patients suffering from musculoskeletal pain; to identify their internal and external resources in order to strengthen their belief that their life is meaningful , comprehensible , and manageable . Thus, clinicians could help patients shift their focus away from crises, but instead view the encounters as balanced and meaningful .Based on a RCT involving a sample of 250 patients with persistent musculoskeletal pain who received care in VA primary care clinic, this study found that a strong SOC was independently associated with better HRQoL and self-efficacy, as well as less pain catastrophizing, after adjusting for sociodemographic and socioeconomic characteristics, and medical comorbidities. In contrast to most previous studies, the present study was able to adjust for presence of probable major depressive disorder. The significant associations between SOC and the aforementioned outcomes remained moderate in magnitude and statistically significant. The results also indicated that the “absence of major” depression had a strong and independent association with better HRQoL and pain-specific outcomes in all models. Finally, coping capability, like SOC, are needed to improve HRQoL for primary care patients suffering from musculoskeletal pain.HRQoL: Health related quality of life; SOC: Sense of coherence; SCOPE: Stepped care to optimize pain care effectiveness; VA: Veterans affairs; ICD-9: International classification of diseases, ninth revision; BPI: Brief pain inventory; ASES: Arthritis self-efficacy scale; CSQ: Catastrophizing strategies questionnaire; SF-36: the 36-item short-form health survey; SF-12: the 12-item short-form health survey; PHQ-9: 9-item patient health questionnaire.The authors declare that they have no competing interest.All authors contributed to and have approved the final manuscript. NRC contributed with the literature review, interpretation of the analysis, as well as drafting and revision of the manuscript. KK was responsible for the development and design of the study, interpretation of the analysis, diagnostic issues of the clinical sample and revision of the manuscript. SO was responsible to original outline of the manuscript. MJB contributed to the interpretation of the data and revision of the manuscript. EK contributed to the recruitment and diagnostic issues of the clinical sample and revision of the manuscript. ZY and JW contributed to both data management and data analysis.


Background. The dose of alcohol used in EUS-CPN is not standardized. The objective was to compare the safety of 20 mL alcohol versus 10 mL alcohol during EUS-CPN for patients with pancreatic cancer-related pain. Methods. 20 patients were selected to receive 10 mL or 20 mL of alcohol during EUS-CPN. Followup was done at baseline, 24 hours, and weekly. Health-related quality of life (HRQoL) was assessed at baseline, week 2, week 4, and every 4 weeks thereafter until pain returned. Results. There were no major complications in both groups. Minor self-limited adverse effects were seen in 6 (30%) subjects and included lightheadedness in 1 (5%), transient diarrhea in 2 (10%), and transient nausea and vomiting in 3. Pain relief was similar in both groups: 80% in the 10 mL group and 100% in the 20 mL group (P = 0.21). The mean (± SD) duration of pain relief in the 10 mL and 20 mL groups was 7.9 ± 10.8 and 8.4 ± 9.2 weeks, respectively. 30% of patients in each group had complete pain relief. Conclusions. EUS-CPN using 20 mL of alcohol is safe. Similar clinical outcomes were seen in both groups. Further investigations to confirm these findings are warranted. One of the main concerns of patients with pancreatic cancer is pain . For patThe amount of alcohol used in EUS-CPN ranges from 2 to 20 mL of alcohol –18. TherThis study was approved by the Institutional Review Board at Indiana University Medical Center. Consecutive patients with known or suspected unresectable pancreatic cancer and pain were enrolled. Written informed consent to participate in this study was obtained from all patients enrolled. Patients were excluded if they had the following: previous CPN (endoscopic or percutaneous), an implanted pain relieving device, or an arterial abdominal aneurysm. Patients were selected to receive 20 mL of 0.75% bupivacaine followed by 10 mL or 20 mL of alcohol for EUS-CPN. Opioid use was not a prerequisite for entry into this study. Pain relief was defined as a pain score less than or equal to 4, or at least a 30% decrease in the pain score compared to baseline pain without an increase in pain medication usage. EUS-CPN is defined as injection of a neurolytic agent into the celiac plexus area or directly into celiac ganglia. After providing informed consent, subjects were sedated with intravenous fentanyl, midazolam, and/or Propofol. A 22-gauge hollow Echotip Ultra needle  was passed through the working channel of the echoendoscope, through the posterior wall of the stomach and directly into the celiac ganglia Figures  when visBaseline pain medication use and pain scores were documented for each patient. Each patient was called at 24 hours and weekly by a blinded research coordinator. Followup continued until the patient reported a return of their pain to baseline or died. Patients rated pain using a numeric rating scale (NRS) that ranges from 0 to 10 where 0 is “no pain” and 10 is “worst pain.” During each phone interview, patients were also asked to quantify their use of pain medications. During each phone interview, the subject's pain was assessed using the brief pain inventory (BPI). The BPI is a three question survey that rates intensity of pain (severity) and interference of pain with mood, physical activity, work, social activity, relations with others, sleep, and enjoyment of life , 20. TwoThe frequency of complications was calculated. Complete response was defined as a pain score of zero without an increase in pain medication usage. Kaplan-Meier estimates of duration of pain relief were calculated. Health-related quality of life (HRQoL) scores were summarized for each patient. Patients who died while still experiencing pain relief are censored from our calculation of pain-free survival. Patients who did not achieve pain relief within the first four weeks of followup are assigned zero for duration of pain relief and were not be censored. The overall survival is calculated from the time of EUS-CPN. P = 0.69). In patients who did not have direct injection of celiac ganglia, the median (range) duration of pain relief 3 (2–8) and 1 (1–14) for the 10 mL and 20 mL alcohol groups, respectively, (P = 0.19). A Kaplan Meier survival curve is shown in Patient characteristics are demonstrated in HRQoL at the week 4 of followup is shown in There were minor self-limited postprocedure adverse effects in 6 subjects including lightheadedness in 1 (5%), transient diarrhea in 2 (10%), and transient nausea and vomiting in 3 (15%). Only subject in the 20 mL group required an emergency room visit for pain control at week 2. There were no complications of bleeding or paralysis.There were no major complications seen with the 20 mL of 98% alcohol group compared to the 10 mL group. During the EUS-CPN procedure all patients received a combination of fentanyl, versed, and propofol for sedation which likely explains the absence of pain in the recovery room. We found that EUS-CPN with 20 mL of alcohol compared to 10 mL of alcohol was safe. However, we also noted that clinical outcomes of the two groups were similar with respect to overall pain relief (100% in 20 mL group versus 80% in 10 mL group), weekly pain scores, onset of pain relief, duration of pain relief, and proportion of complete responders. This suggests that 20 mL alcohol during EUS-CPN may not provide significant pain relief despite its safety. A statistically significant difference is not observed between the two groups, however, as our study was a pilot study. A larger prospective study is warranted to confirm our findings. We also noted an equal number of complete responders in each group. Two thirds of these complete responders in each group had direct injection of celiac ganglia. This suggests that direct visualization and injection of celiac ganglia may improve the accuracy of EUS-CPN. The overall efficacy, however, of EUS-CPN is likely explained by the diffuse spread of alcohol in the celiac region which likely explains this result. With respect to pancreatic pain, digestive symptoms, nausea, and vomiting, relatively better HRQoL scores were seen in the 20 mL group. This finding has not previously been reported, and a larger prospective study is necessary for confirmation. There is a subtle trend in improved survival in the 20 mL group. Survival in general may be related to pain relief and may reflect the patient's ability to perform daily activities of living and have better nutrition. A larger prospective study, however, is necessary to confirm these observations. It has been reported that patients with pancreatic cancer have lower pain scores and pain medication consumption up to 16 weeks after EUS-CPN , 21. In In our study minor self-limited postprocedure adverse effects were seen in a third of subjects including transient lightheadedness, diarrhea, nausea, and vomiting. Our experience is similar to previous reports of adverse effects including diarrhea (17%), postural hypotension (1%), and postprocedure-related abdominal pain (9%) , 31. In Lillemoe and colleagues demonstrated improved survival after intraoperative CPN  in a double-blinded randomized placebocontrolled study of 139 subjects with unresectable pancreatic cancer . The main limitation of our study is the size. In our pilot study we have demonstrated preliminary evidence that EUS-CPN 20 mL 98% alcohol appears safe. Injection of ganglia appears to improve accuracy of EUS-CPN and possibly the duration of pain relief. A larger prospective trial is warranted to confirm our findings and further understandhowto examine the potential predictors of adjuvant therapy  and direct ganglia injection (versus injection into the celiac region) on the clinical outcomes of pain relief, quality of life, and survival.


Aim: The bone scintigraphy is indicated in patients with costochondral pain in order to identify the organic etiology. We aimed to investigate the local and projecting pain, or incidental findings in the three phase bone scintigraphy of the patients referred for costochondral pain.Methods: We included 50 patients  referred to our department for three phase bone scintigraphy for costochondral pain between January 2009-July 2012.Results: Among the 50 patients 22 had normal scintigraphy. An increased activity accumulation in the sternoclavicular joint was observed in 12 patients  only in late phase and in 9 patients  with increased vascularity. Among projecting pain causes, activity was present on sternum in 4 patients, on humerus in 2 patients and on the first costae in 2 patients. For the characterization of inflammatory pathology, the three phase bone scintigraphy showed sensitivity, specificity, accuracy, positive and negative predictive values of 43%, 94%, 78%, 77% and 78% respectively.Conclusion: Bone scintigraphy is an effective diagnostic method for the identification of local or projecting pain, and additionally unexpected incidental pathologies ssociated with costochondral pain. However regarding the characterization of inflammatory process false negatives should be considered.Conflict of interest:None declared. The causes of the chest wall pain include costochondritis, Tietze’s syndrome, traumatic chest pain, and systemic rheumatoid diseases . Tietze’Bone scintigraphy is a diagnostic test employed in both diseases ,4. Yang These kind of chest wall pain causes significant loss in health related quality of life, and waste of time, if the diagnosis is delayed. Bone scintigraphy has power to identify the etiology associated with these syndromes, thus early diagnosis and treatment or exclusion of the pathology might be possible. The aim of this study was to evaluate the contribution of the bone scintigraphy in patients with chest wall pain. We retrospectively investigated the bone scintigraphy results of the patients who were referred to our department due to chest wall pain. We included 50 patients  referred to our department for three phase bone scintigraphy for costochondral pain between January 2009-July 2012. All the patients had an anamnesis of a sudden onset of bilateral or unilateral pain in the costochondral joints, and a tenderness with or without swelling or erythema. The patients who responded to nonsteroidal anti-inflammatory treatment were not included in the study group. The mean sedimentation rate, C-reactive protein (CRP) and rheumatoid factor (RF) levels of the patients were 16±20 mm/h (range: 0-20), 5.2±4.9 mg/L (range: 0-5) and 9.6±0.5 IU/mL (range: 0-15) respectively.Three phase bone scintigraphy was performed to all patients with additional whole body imaging Bone scintigraphy was performed by the intravenous administration of approximately 20 mCi (750 MBq) (according to the body weight) of 99m-Tc methylene diphosphonate (MDP). Dynamic and static imaging was performed just after the injection of the radiopharmaceutical, and 2-3 hours after the injection, respectively, by double head SPECT gamma camera  with parallel hole low energy high resolution collimator. An additional SPECT imaging was performed to six patients from thoracic region.An experienced nuclear medicine physician evaluated the bone scintigraphy results retrospectively without the knowledge of other clinical parameters or imaging findings. The scintigraphy results were classified as inflammatory (if increased vascularity accompanies the late phase increased osteoblastic activity) and non-inflammatory (increased activity accumulation in the late phase only) or normal.The final diagnosis was decided according to the decision of the clinician with the results of physical examination (presence of swelling in conjunction with pain considered inflammatory pathology) and/or laboratory parameters (elevation of plasma sedimentation rate or CRP or RF levels considered positive findings for inflammation). Morphological imaging methods were employed if the decision was not established based on scintigraphy or other laboratory results.Local ethics committee approved the study, and the study was conducted according to the Helsinki Declaration. Informed consent of the patients was obtained. Among the 50 patients 22 had normal scintigraphy, and sternoclavicular increased activity accumulation was observed in 12 patients  only in late phase and in 9 patients  with increased vascularity . Among pAccording to the final decision regarding presence or absence of inflammatory pathology the sensitivity, specificity, accuracy, positive and negative predictive value of the three phase bone scintigraphy were 43%, 94%, 78%, 77% and 78% respectively. -bBone scintigraphy revealed information regarding both inflammatory and degenerative changes related to the pain of the patients and served as a guide for clinicians in the management of the disease. Besides by providing additional information about the projecting pain causes and unexpected malignant tumors contributed to the patient management. Thus bone scintigraphy can be regarded as a beneficial imaging modality in patients with chest wall pain with undefined etiology. Freeston et al. evaluated the importance of early diagnosis and management of costochondritis and found out that rapid diagnosis improves the patient care and reduce the number of admissions of these patients .The patients with chest pain usually attend to the emergency room with anxiety of having heart attack or a malignant pathology related to the breast. The patients with inflammatory process in the costochondral joints also present with chest pain and have the same concerns. Since the time to diagnose the disease is prolonged, the anxiety of the patient increases. Rapid diagnosis and appropriate management cause prevention of these social and health related problems.The patients with costochondral pain usually present with an acute pain with or without an accompanying event like trauma, emotional stress or recent surgery . TendernThe costochondritis has an unexpectedly high frequency according to the literature, it comprises 30% of the chest pain causes . Peyton Although bone scintigraphy is a sensitive method for most of the bone pathologies it is usually considered not specific enough for diagnosis. A similar observation for costochondral pathologies was also made by Mendelson et al. who compared their findings in costocondral patients with control subjects . AlthougAny pathological process can mimic this syndrome. In a previous case report a patient mimicking Tietze’s syndrome with a mediastinal squamous cell cancer metastasis with unknown primary had been reported . In our Although chest wall pain is a frequent complaint and scintigraphy is a sensitive diagnostic method there are not plentiful studies especially with large patient population in the literature. Our study includes a sufficient number of subjects, however limitations are its retrospective method and lack of patient follow up results. Prospective studies in this group of patients with bone scintigraphy are warranted in the future.Our results show that bone scintigraphy might contribute to the management of the patients with costochondritis by demonstrating the costochondral, projecting and accompanying pathologies.


Congenital Insensitivity to pain with anhydrosis (CIPA) is a rare inherited disease. It is classified as hereditary sensory and autonomic neuropathy type IV. Pain insensitivity and autonomic deficits are present, but touch and pressure sensitivity are unimpaired. Mental retardation is usually present. We report a family case of a 5 years old girl and 2 years old boy with congenital insensitivity to pain, while discussing the clinical features and the anesthetic strategy of such patients. Patients with Congenital Insensitivity to Pain with anhydrosis may undergo surgery because of susceptibility to trauma due to absence of pain. The clinical features may intrinsically possess anesthetic challenges. Congenital insensitivity to pain with anhydrosis (CIPA) or hereditary sensory and autonomic neuropathy type IV (HSAN IV) is a rare autosomal recessive neuropathy of the group of hereditary sensory and autonomic neuropathies (HSAN), first described in 1932 by Dearborn as “Congenital pure analgesia” [Written informed consent was obtained from the patient for publication of this case report and accompanying images. A 5 years old girl and a 2 years old boy, siblings, were born after a normal pregnancy and normal delivery. They were the only children of a healthy family and of a non-consanguineous marriage. There were no family history of neurologic or metabolic disorders and no other member of their family was diagnosed with CIPA.They were brought by their parents looking for a therapy that could avoid injuries to their oral structures and the finger biting. Their physician had suggested full mouth extraction, but the parents did not agree because of the psychological and functional implications.Their parents relate a history of self-mutilation from first months of life. After their teeth started to grow in, they began to chew their fingers and bit off the tip of their tongue, since eruption of the teeth there had been biting of their tongue, fingers, wrists, and feet, causing bleeding. They exhibited an absence of normal reaction to painful stimuli such as falls, cuts, and injections (e.g.: for vaccinations).On admission, they were poorly developed and thin, their tongue and upper lip had been bitten off. They had scars from injuries and they had self-mutilation of interphalangeal joints of the fingers and toes . The disParaclinical investigations were common to both patients. Laboratory examination including white blood cell, hemoglobin, serum electrolytes, GOT, GPT, renal function value, uric acid, creatine kinase, were normal. Hands and feet radiograph showed destruction and amputation of fingers and toes .Once the diagnosis was confirmed, the patients benefited from a multidisciplinary management. Self-mutilation of the tongue, lips and fingers had posed difficult problems since the dental eruption; stomatologists tried to make a mouth guard, they estimate that extraction of all primary teeth was a radical alternative that should be considered only if all other possibilities failed or in extreme cases. Psychological support to the patients and the family were also necessary. Genetic counseling was indispensable given the seriousness of the disease. Parents were also advised to consult in cases of fever to eliminate a potential infection and in case of injury to detect an unnoticed fracture.There are number of diseases that affect sensory function from birth. Dick  classifiCIPA is characterized by insensitivity to superficial and deep painful stimuli with intact tactile perception, self-mutilation, recurrent unexplained fever in infancy, anhydrosis, mental retardation, absent or hypoactive deep tendon reflex, normal corneal reflex and lacrimation and autonomic nervous system abnormality.Autonomic abnormalities include the inability to sweat in response to heat or chemical stimuli (pilocarpine) and the production of a wheal but not a flare after intradermal histamine injection . IndividIt may be thought that patients with CIPA do not need anesthesia to undergo surgical procedures because of the insensitivity to pain. However, the tactile sensation is intact and some patients have tactile hyperesthesia . Some paSome authors described the difference in concentration of inhaled anesthetics needed for orthopedic surgery and dental surgery. According to their report, the inhaled anesthetic was≥1 MAC for orthopedic surgery, and≤1.0 minimum alveolar concentration for dental surgery. They speculated that these differences were caused by the nociceptive stimulus of each operation. However, there have been few reports concerning the anesthetic management of patients with CIPA because it is a rare disease ,9. PatieCongenital hyposensitivity to pain is a rare disease, and there is limited information regarding anesthetic treatment of these patients. Okuda et al  reportedTomioka et al  reportedThe primary anesthetic concern in patients with HSAN type IV is impaired temperature control, which can cause death in about 20% of the affected patients within the first 3 years of life . Strict There are reports of surgical procedures without anesthesia in patients with CIPA, such as the case of a patient who underwent amputation of both feet under sedation  or general anesthesia. He did not show any response to incision of the skin or disarticulation, and he only reacted to clamping of a nerve trunk with flexion of a limb . An eighCongenital insensitivity to pain with anhydrosis (CIPA) or hereditary sensory and autonomic neuropathy type IV (HSAN IV) is a rare autosomal recessive neuropathy of the group of hereditary sensory and autonomic neuropathies (HSAN). Patients with CIPA may undergo surgery because of susceptibility to trauma due to absence of pain. The clinical features may intrinsically possess anesthetic challenges.


Low back pain is one of the most common ailments in the general population, which tends to increase in severity along with aging. While few patients have severe enough symptoms or underlying pathology to warrant surgical intervention, in those select cases treatment choices remain controversial and reimbursement is a substancial barrier to surgery. The object of this study was to examine outcomes of discogenic back pain without radiculopathy following minimally-invasive lateral interbody fusion. Twenty-two patients were treated at either one or two levels  between L2 and 5. Discectomy and interbody fusion were performed using a minimallyinvasive retroperitoneal lateral transpsoas approach. Clinical and radiographic parameters were analyzed at standard pre- and postoperative intervals up to 24 months. Mean surgical duration was 72.1 minutes. Three patients underwent supplemental percutaneous pedicle screw instrumentation. Four (14.3%) stand-alone levels experienced cage subsidence. Pain (VAS) and disability (ODI) improved markedly postoperatively and were maintained through 24 months. Segmental lordosis increased significantly and fusion was achieved in 93% of levels. In this series, isolated axial low back pain arising from degenerative disc disease was treated with minimally-invasive lateral interbody fusion in significant radiographic and clinical improvements, which were maintained through 24 months. Intervertebral disc degeneration in the spine is natural process of aging and in many cases is asymptomatic . HoweverConservative (nonoperative) care for LBP, while covering many different modalities, generally includes treatment with NSAIDs, weak opioids, and exercise therapy . When exThe objective of this work was to evaluate minimally invasive lateral interbody fusion in the surgical treatment of lumbar discogenic pain, and to perform a literature review of degenerative disc disease and its treatment in the literature.Data were collected through retrospective review of prospectively collected clinical and radiographic registry at a single institution. Inclusion in the current study included consecutively treated patients with degenerative disc disease presenting with discogenic low back pain without radicular symptoms, after failing at least 6 months of conservative care. Discogenic pain was assessed by clinical examination , such asPatients were treated via the minimally invasive, lateral retroperitoneal transpsoas approach . The surClinical evaluations were performed by a clinical and included a physical exam for lower extremity motor and sensory function and self-assessed questionnaires using the Oswestry disability index (ODI) and visual analogue scale (VAS) for back and leg pain. Evaluations were performed preoperatively and at 1 and 6 weeks, 3, 6, 12, and 24 months postoperative. Minimum follow-up for inclusion in the current analysis was 24 months postoperatively.Bony fusion was assessed by two spine surgeons and two spine researchers in CT scans and dynamic X-rays. Fusion was considered complete when translational motion was <3 mm, angular motion was <5°, and >50% of disc space showed complete bony bridging.t-testing to evaluate differences in mean outcome variables from pre- to postoperative time points. Statistical analyses were performed using SPSS software  and statistical significance was evaluated at P < 0.05.Statistical analyses included descriptive statistics to characterize baseline variables and paired From 220 patients that underwent lateral interbody fusion for degenerative disc disease between August 2007 and December 2009, 22 (10%) patients met inclusion-exclusion criteria  with 28 spine levels treated. One- and two-level procedures were performed in 16 (73%) and 6 (27%) cases, respectively. Levels treated included L2-3, L3-4, and/or L4-5.Surgical procedures were performed in an average of 72.1 minutes (range 40–110 min) with an average blood loss of less than 50cc. The average hospital discharge was 21 hours (range 8–44 hours). Intraoperative complications included one instance of anterior longitudinal ligament rupture, which resulted in the placement of posterior pedicle screws. No other intraoperative complications were observed. Three patients (5 spine levels) required supplemental percutaneous pedicle screw instrumentation for grade I spondylolisthesis with instability, while other cases (23 spine levels) were performed as stand-alone interbody constructs.Four stand-alone levels experienced cage subsidence (14.3%) by 6-week followup. These patients experienced transient axial back pain  and in one (4.5%) case radiculopathy arose, which required a foraminotomy 12 months postoperative.Clinical outcomes improved postoperatively . LBP, asP = 0.032). Bony fusion was observed in 92.9% (26/28) of total lumbar levels treated  to 16.7° (6.5° SD) at final followup P = 0.02. Bony fThis work examined the treatment of discogenic LBP in patients with degenerative disc disease treated with a discectomy and interbody fusion via lateral access. Isolated axial low back pain rapidly resolved after surgery and disability more gradually improved, as would be expected. Radiolographic analysis revealed improvements in segmental lordosis at treated levels and a high rate of solid fusion. Additionally, few complications occurred, as would be expected using a modern minimally invasive approach, and the patients were generally treated successfully through removal of the pathological intervertebral disc and by stabilizing and fusing the level.This work represents a retrospective study on prospectively collected data in a small case series with midterm followup, so conclusions are limited to the study design drawbacks. The primary reason for a small sample size was the relative infrequency of surgical candidates for lumbar spine fusion surgery without radicular symptoms . This strengthens the results through sample homogeneity, but greatly limited the sample.Intervertebral disc morphology continuously changes from birth to late stages of the human life . Disc deVarious phenomena are involved in lumbar disc disease. Genetics, trauma, nutrient pathways, cell death, and matrix synthesis can be primary degeneration inductors  and biomAlthough in normal anatomy, intradiscal nerve terminations have a limited distribution , disc degeneration has been shown to have a massive ingrowth of nerves fibers –32. ThesOne of the most challenging factors of discogenic low back pain is an accurate differential diagnosis. Morphological and functional statuses of apophyseal joints, ligaments and musculature and spine biomechanics must be analyzed , 34–36. Classically discs are innervated segmentally and discogenic pain pathways flow through the sinuvertebral nerve into the corresponding dorsal root ganglion and into the spinal cord, generating symptoms located at the index level , 40, 41.Identification of signs and symptoms of discogenic back pain includes continuous axial low back pain persistent in extended period deep in the central line of the spine, usually with no irradiation , possible relief when lying, no significant worsening with movements, and worsened with axial load and long standing or sitting periods. In radiolographic analysis, low signal intensity of the disc on sagittal T2W, high-intensity zones, annular damages, and especially Modic changes corroborate clinical findings , 36, 43.Provocative discography is one of the possible tests to contribute in the diagnosis of discogenic pain, but a few studies have shown equivocal results for discography –46 and tWhen a degenerated intervertebral disc is determined to be the primary pain generator, surgical removal must be considered. Nucleus replacement was one attempt to treat discogenic pain and maintain movement and function, but the ideal indication window is too narrow and several unwanted complications have occurred –52. LumbFor a painful disc, discectomy and interbody fusion intend to remove the pathologic tissue, which presents itself as nonfunctional fibrotic structure, soaked with inflammatory mediators and nerve ingrowth, and to fuse the segment. Additionally, index motion is related to pain occurrence and can be treated with lumbar level stabilization, and the addition of interbody fusion has show the favorable results in lumbar fusion , 58, 59,Lateral interbody fusion has been shown to significantly increase foramen and disc height , impact If the affected lumbar level does not present with gross instability, a stand-alone interbody construction may be considered. In this instance, posterior muscle damage is prevented as well as posterior instrumentation complications. Biomechanical studies  have shoPayment and reimbursement for lumbar fusion, especially for degenerative disc disease, are being rigorously reviewed by North American and worldwide institutions with the premise that it is ineffective. In this study, however, at 2 years postoperatively over 70% improvement in VAS and patient outcomes was demonstrated, much higher than previous studies on treatment for degenerative spine condition , 73–76.


Perioperative symptoms such as pain and anxiety are common in spite of standard of care. Such symptoms are associated with a negative surgery experience, and moreover, are correlated with increased perioperative morbidity. The aims of this study were to evaluate whether acupuncture as an add-on to standard of care improves these symptoms. In addition, we assessed whether outcomes are correlated with expectations from CAM.We conducted a pragmatic trial of 479 adult patients undergoing various abdominal operations. Eighty-nine patients received standard medical care, and 390 patients received acupuncture on top of standard medical care, according to patient preference and practitioner availability. Numeric VAS scores for anxiety, pain, nausea and well-being were collected pre and post treatment. Acupuncture was provided according to Traditional Chinese Medicine syndrome categorization.There was a significant reduction of VAS scores for all outcomes in the acupuncture group: Anxiety scores were reduced from 4.4 to 2.6 , pain from 4.8 to 2.5 , nausea from 2.7 to 1.4  and well-being improved from 5.1 to 6.8 . Symptomatic improvement was significantly better in the acupuncture group as compared to the standard of care group for all parameters p<0.0001. In the subgroup of patients experiencing moderate to severe symptoms, improvement was even more prominent: anxiety scores were reduced from 6.9 to 3.8 ; pain from 6.9 to 3.6 ; nausea from 7.2 to 3.3 ; and well-being improved from 3.7 to 6.2 . We did not find a correlation between outcomes and patients’ expectations regarding acupuncture.Our results demonstrate that acupuncture therapy significantly improved common symptoms in patients undergoing surgical interventions.


Chronic and recurrent pain is experienced by many children and adolescents. Treatment of chronic pain using a multidisciplinary approach has been found to be effective for treatment of chronic pain. Parent satisfaction with treatment and treatment providers highly correlates to children's treatment adherence. Parents of children treated at a multidisciplinary chronic pain clinic were interviewed following their initial appointment. Parents reported high satisfaction with treatment team members and with the treatment plan. Parents also reported appreciation of multidisciplinary structure, the high level of expertise of the team members, and the team members' genuine interest in treating their children. This increase in satisfaction when compared to previous treatment is important since increases in satisfaction may correlate with a reduction in experiences of chronic pain. Parents reported high satisfaction with interactions with treatment team members and with the treatment plan provided for their children. Parents had appreciation of multidisciplinary team structure and the high level of expertise of the team members. This increase in satisfaction when compared to treatment from previous providers is important since increases in satisfaction may correlate with an increase in children's treatment adherence and a reduction in experiences of chronic pain. Chronic, persistent, and episodic pain has a prevalence rate of 25 to 33% in childhood and adolescence . TreatmeFamilies often report limited belief by health care providers regarding the high levels of pain their child is experiencing, which can interfere with the trust and relationship the families create with the providers. Parents may experience a general distrust of the medical system and frustration with a lack of conclusive medical tests , decreasSince chronic pain is not solely a response to physical sensations, a biopsychosocial approach to treatment is beneficial . DespiteThe use of a multidisciplinary approach to treatment has been found to be more acceptable to parents and patients than a focus only on the medical factors of pain, and families note that providers in these multidisciplinary settings displayed a noted interest in understanding the pain and increasing the comfort of the families during the appointment . This foThe current literature provides information regarding the importance of using the biopsychosocial perspective for treating patients with chronic pain; however, it is currently unclear how parents of patients with chronic pain perceive the multidisciplinary team approach to treatment using the biopsychosocial perspective. In the current literature, there is some information regarding parents' perceptions of treatment provided using the biopsychosocial perspective; however, this information is not based on patients with various types of chronic pain. The current study assesses treatment provided at a multidisciplinary chronic pain clinic treating various types of chronic pain, such as headache, abdominal pain, and musculoskeletal pain. The current study adds to the literature an understanding of parents' perceptions of the multidisciplinary team approach to treatment of their children's chronic pain.The multidisciplinary clinic team includes a pediatric anesthesiologist with specialization in pediatric pain, a licensed clinical psychologist, a licensed marriage and family therapist, and physical and occupational therapists. Each year, this multidisciplinary clinic has an average of 280 intake appointments for children with various chronic pain concerns. Patients are typically referred to this clinic by their primary care physician or by a specialist after other medical services provided have failed to alleviate their pain experiences or testing has resulted in no organic etiology of pain experience.For all initial pain clinic evaluations, the patient and parent(s) meet with a physician and psychologist or family therapist for a 1.5 hour visit. The family is interviewed jointly for the medical history and general functioning information. Then while the physician and, if appropriate, physical therapist conduct a physical assessment of the patient, the mental health provider interviews the parent(s). After the physical exam is completed, the mental health provider interviews the patient. The physician and mental health provider then meet briefly to draft a treatment plan, which is then presented to the family. The multidisciplinary team intervention during this visit includes careful attention to medical and illness narratives and family beliefs and expectations, validation and acknowledgement of challenges and strengths, development of a shared rationale for understanding patient and parent distress, testing parental and patient receptiveness to initial reframes of maladaptive beliefs, provision of a rationale for treatment recommendations, and development of a comprehensive treatment plan. Treatment plan recommendations are individually tailored and may include medication management, physical therapy, individual and family cognitive behavioral therapy, school accommodation and return to school plan, collaboration with existing medical and mental health providers and school staff, and pain team followup.Parents were asked to share their experiences and perspectives of the initial intake appointment. Questions included their initial expectations of the intake appointment and treatment plan, how these expectations changed during and after the appointment, and their perceptions of the structure of the multidisciplinary nature of the intake appointment (see Appendix). The initial appointment at the multidisciplinary clinic is family-centered treatment and structured for collaboration not only between the multiple health providers but also between the providers and the family members. In the initial appointment, the health providers strive to increase families' understanding of the pain within the biopsychosocial model, to increase families' trust in the team, to provide the families with a comprehensive treatment plan, and to increase families' hope in restoring functioning and possibly reducing youths' pain experiences.Data was collected from nine parents of adolescents that were seen as outpatients at a pediatric pain management clinic in a large mid-western city for the treatment of their chronic pain. During the initial appointment, members of the multidisciplinary pain treatment team gave a brief written description of the study to the parents. Parents who were interested signed consent forms and an appointment was scheduled for the interview to be conducted in the family's home within one week of the initial intake with the multidisciplinary team. This study was reviewed and approved by the university's and local hospital's IRB committee. No parents were excluded from the study based on gender, race, or ethnicity.17). Based on the CQR methodology, we explored and described in depth parents' expectations and experiences during an intake encounter with a multidisciplinary pain team. Our study used an open-ended interview to capture the parent's experience in order to describe the phenomena as it naturally occurred. No specific hypotheses were developed; instead, inductive analysis was used to draw conclusions from the data obtained by the parent's responses. CQR is a replicable method that instills scientific rigor by using multiple researchers that form a consensus on decisions and verify results. Furthermore, using multiple researchers helps minimize bias by sharing a variety of opinions and perspectives that capture the data [This study utilized a qualitative design based on Consensual Qualitative Research CQR. Based oProviders at the multidisciplinary clinic, in collaboration with researchers from the counseling and clinical psychology program, developed the interview protocol based on clinical experience and literature related to multidisciplinary pain treatment and adolescent chronic pain. The interview guide included open-ended topics such as expectations and experiences prior to the clinic appointment, description of thoughts and feelings about the appointment, and treatment recommendations (see Appendix).Members from the counseling and clinical psychology research teams and researchers from the medical college completed nine interviews. The interviews took place at the patient's residence to ensure comfort and confidentiality. All questions were asked to each parent and lists of probes were used to gather any additional information or clarification. Furthermore, additional probes were used to explore issues that emerged in the interview for each participant . All intThe primary coding team consisted of three clinical psychology doctoral students, who were not involved in interviewing participants. All members read articles , 18 and There were several steps in the procedures for analyzing the data. First, domains  were constructed by dividing up the responses to the open-ended interview questions. Second, core ideas  were formed from all the material from each domain for each parent's response. Third, cross-analysis was performed by finding common themes transcending the domains and core ideas. Along the process, the primary team made judgments about each decision until consensus was reached and the best structure developed. At each step, the raw data was continually reviewed making sure the final decisions were based on the data. Lastly, the auditor viewed the judgments during the cross analysis stage to ensure the primary team did not fail noticing any of the essential data . That isThe purpose of this study was to examine parents' thoughts and feelings about their child's chronic pain, past treatment, and initial evaluation by a multidisciplinary chronic pain team. Overall, 14 domains were identified based on the content across all nine interviews. Within these domains, 85 core ideas were determined to exist across interviews. According to the procedure described by Hill and colleagues , categorWe've been from doctor… to doctor and we still do not really have a diagnosis”), having been seen in a hospital for pediatric pain, and using medication to manage pediatric pain. Parents also typically discussed never having had a treatment plan in place for the child's pain before coming to the pain clinic. Variant reports include information about the child having undergone surgery for pain and statements about the child never having met with a team of providers before to treat their pain .The domain Patient's Prior Treatment for Chronic Pain contains objective descriptions of the child's past treatments for pain. This domain includes four typical  and two variant (Surgery and Team Novelty) core ideas. Parent reports typically described seeing a variety of medical providers for their children's pain  and disagreements with the provider's recommendations for treatment . Typical reports from parents also include information about both positive and negative interactions with past providers.The domain Parent-Past Provider Relationship describes parents' contact and rapport with past medical doctors. This domain includes five typical  and four variant  core ideas. Typically, parents discussed a general lack of centralization of providers at many hospitals, their general problems with hospital systems, seeing providers for only short amounts of time at their appointments , providers having a general lack of expertise in treating pediatric pain, and statements by parents about how they think the provider should share some information with the parent without the child in the room. Finally, variant reports also describe difficulty with inadequate health insurance coverage .Parent reports that were categorized as variant include providers not believing the child or not taking the pain seriously , descriptions of stressful situations surrounding child's pain and parents' negative emotions about child's pain, . Variant topics include the importance of adherence to the team's treatment plan to alleviate pain, the parents' desire to eliminate their child's pain , the need for improving the child's level of functioning while having pain , the parents' feeling that they cannot do anything to alleviate their child's pain , the parents' attitudes towards their child's treatment for pain, and the frustrating experience of having unknowns about treatment and diagnosis of child's pain .The domain Parent Attitudes toward Pain includes any attitude expressed by the parent regarding pain, pain management, and related areas of functioning. This domain includes three typical  and six variant  core ideas. Typical parent interviews refer to parents' aversive attitudes towards managing pediatric pain with medications . In typical interviews, parents expressed not knowing what would occur , mixed expectations , or no expectations about the appointment at the pain clinic. Variant interviews include reports of low expectations about the clinic appointment and discussions about the clinic appointment being with a team of providers rather than a single provider.The domain Parent's Preconceptions of Appointment includes information about parent's emotions and thoughts about going to the clinic prior to the clinic visit. This domain includes one general (Hope), three typical , and two variant (Low Expectations and Meeting with Team) core ideas. Hope is a general theme across interviews; eight of the parents interviewed expressed hope for treatment's effectiveness in decreasing the child's pain .The domain Parent Attitudes toward Multidisciplinary Team includes statements regarding parents' positive or negative thoughts and emotions regarding the general experience with the multidisciplinary team and approach. This domain includes one general (Positive Shift in Emotions), 13 typical , and three variant  core ideas. Generally, parents described feeling more positively about attending the clinic throughout and after the appointment , the inclusion of the child in appointment discussions and also having time to talk about the child with team members without the child . Also regarding the multidisciplinary approach of the clinic, parents typically described the team's thoroughness and breadth in addressing all aspects of child's pain , the collaboration or “think tank” style of the team , the potentially long-term commitment and efforts of team members to alleviate the child's pain, and the expertise or experience of the team members in treating pediatric pain. Parents also typically reported their expectations regarding the appointment and/or care being exceeded or met by the team, and expressed their faith or hope in the team's ability to alleviate the child's pain.Typically, parents reported positively about the organization of team members and team preparation for the appointment, the warmth of the team members  and emotions regarding the team members which were neither positive nor negative.Core ideas classified as variant include statements about the family being appreciative of not having to retell the medical history repeatedly due to the multidisciplinary approach of the clinic, some negative interactions with the team , while others made statements indicating negative attitudes towards the team, treatment, and appointments. Variant reports indicate neutral or positive attitudes towards the treatment, respectively.The domain Child's Attitude toward Multidisciplinary Team was applied to parents' recounting of child's thoughts and emotions regarding the experience of the multidisciplinary approach. This domain includes two typical (Negative Attitude and Team Positive) and two variant  core ideas. Typically parents reported statements made by the child indicating positive attitudes towards the team  and describing the provider as nice, personable, and approachable . Variant core ideas include descriptions of the provider's focus on eliminating or ending the child's pain and of the individually focused care of the provider .The domain Parent-Clinic Provider Relationship describes parents' contact and rapport with individual providers at the pain clinic. This domain includes two typical (Expertise and Warmth) and two variant  core ideas. Typical interviews include parents' descriptions of the provider as knowledgeable and giving good explanations to the family  and the child's desire to not take the medications . A variant theme describes the child's attitude contributing to non-compliance .Patient's Non-Compliance is the domain including information regarding the child's noncompliance with the treatment plan as prescribed by the pain clinic or as implemented by the parents. There are two typical core ideas  and one variant core idea (Attitude) within this domain. Typical reports describe the child's failure of following through with the treatment plan , positive opinions toward medication as part of the treatment plan, descriptions of the mental health aspects of the treatment plan , neutral opinions and statements about the treatment plan, willingness in trying the treatment plan ,and school-related aspects of the treatment plan . The two core ideas classified as variant include statements describing the child as not having had significant improvement  and physical therapy being part of the treatment plan.The domain Treatment Plan includes parents' attitudes, thoughts, and emotions towards the treatment plan given to the child by the pain clinic team. This domain includes six typical  and two variant  core ideas. Typically, parents expressed hope or faith in the treatment plan . Researchers should also assess how the increased hope and increased treatment adherence influence the treatment's efficacy in reducing the child's pain and increasing their level of functioning. Research focusing on these factors could lead to improved treatments for the children with pediatric chronic pain and their families.


Although opioids are the main choice for acute postoperative pain control, many sideeffects have been reported for them. NSAIDs and paracetamol have been used extensivelyas alternatives, and it seems that they are more effective for minor to moderate paincontrol postoperatively when have been used alone or in combination with opioids. Aslaparoscopic cholecystectomy poses moderate pain postoperatively, this study was plannedto assess whether paracetamol is able to provide effective analgesia as a sole analgesicat least in the first few hours post operatively.We evaluated the effect of intravenous Paracetamol on postoperative pain in patientsundergoing laparoscopic cholecystectomy.This is a randomized double- blind clinical trial study. 30 patients ASA class I, aged18 to 50 years, candidate for laparoscopic cholecystectomy were recruited, and randomlydivided into two equal groups. Group A (paracetamol group) received 1 gr paracetamol andgroup B received placebo ten minutes after the induction of anesthesia. 0.1 mg/KgMorphine was administered intravenously based on patients compliant and pain score>3. Pain score and the opioids consumption were recorded in the first six hourspostoperative. Patient's pain was measured by the VAS .The pain score was lower in group A (P= 0.01), but the morphine consumption showed nosignificant difference between the groups (P= 0.24) during the first 6 hourspostoperatively.Although paracetamol (1gr) has caused a better pain relief quality but it is not asuitable analgesic for moderate pain control in acute phase after surgery alone. Pain is an unpleasant sensory and emotional experience associated with actual or potentialtissue damage. Undergoing treatment  may result in theoccurrence of postoperative pain, and this triggers biochemical and physiological stressresponses . Pain is« Whether this drug is effective on opioid consumption in the pain control aftersurgery »Laparoscopic cholecystectomy has become the treatment of choice for most patients withsymptomatic cholelithiasis . We evalIn this double-blinded, prospective, randomized placebo- controlled trial, after approvingby Ahvaz Jundishapur University of Medical Sciences (AJUMS) Ethical Committee, 30 patientsof ASA class I, aged between 18 and 50 years, and scheduled for elective laparoscopiccholecystectomy under general anesthesia were recruited, and randomly divided into two equalgroups in the specified time period. Simple random sampling was performed. Exclusioncriteria contained the presence of: 1 - operation for less than an hour or greater thanthree hours 2- intraoperative bleeding greater than 6 cc / kg of body weight 3 - liver orkidney disease, 4 - patients with opioid or alcohol addiction 5 – patients'reluctance to participate in the study. The severity of pain was documented based on theVAS. The VAS is a standard tool like a 10 cm ruler including 10 numbers beginning from 0 (nopain), and ending at 10 (the most severe pain). The patient was asked to select a numberbased on the severity of pain he or she feels. Intravenous Paracetamol (Proparacetamol) wasformulated for using during the anesthesia or immediately after it. However, otherformulations have no high capability. Proparacetamol is rapidly hydrolyzed by plasmaesterases to form paracetamol, as if a 1000 mg of Proparacetamol can produce 500 mgParacetamol. Parastylaminofenol is the precise chemical formulation of Paracetamol. Throughintravenous administration, the onset of effect is about half an hour, approximatelyone-hour half-life, and 6-8 hours effectiveness. The maximum recommended dose for adults is4 grams in twenty-four hours. In this study, Paracetamol was provided by the COBEL DAROUpharmaceutical company. Patients were divided into two groups of A and B; and they did notreceive any premedication drug before entering the operating room. After the placement ofroutine monitoring in all patients, including Electrocardiomyography and Pulseoximetry,noninvasive sphygmomanometer, and capnography, they received 5 cc / kg Ringer serum. Bothgroups were anesthetized with midazolam 0.03 mg/kg , Propofol 2mg/kg , Remifentanil 1μg / kg over a minute, and Atracurium 0.5 mg/kg, and intubated at minimum possibletime, and connected to a ventilator with % 50 O2, % 50 N2O after ensuring that the tube isin the trachea. Respiratory parameters were adjusted during the operation; so that oxygensaturation, end-expiratory carbon dioxide, and end expiratory volume were 96 -100%, 35-45mmHg, and 10 ml per kg of body weight, respectively. Both cases and controls were the sameas above. During the operation, patients received 0.1 μg/kg/min Remifentanilintravenous infusion and Isoflurane 1 MAC. In the treatment group, intravenous Paracetamolwas injected 10 minutes after the induction of anesthesia with a bolus over 15 minutes (1grParacetamol in 100ml of 0.9 % NaCl). Intravenous infusion of Remifentanil (0.05 μg /kg / min or less) was added based on changes in blood pressure and heart rate more than 10%of base. In the control group, 100 cc 0.9 % NaCl was injected with a bolus over 15 minutesas placebo. During the operation, a dose of Intravenous Atracurium 0.2 mg/kg was repeated inboth groups for every 30 minutes. Higher maintenance doses of Isoflurane were administeredfor increasing the depth of anesthesia, which were continuously controlled with the BIS. Remifentanil was reduced  in both groups, on theextubation time for analgesia. All the operations were performed by the same surgeon.Laparoscopy was initiated after 15 minutes of anesthesia induction, and gas pressure was13-15 mmHg all over the operation. At the end of the operation the neuromuscular blockingaction was reversed by using atropine 0.02 mg/kg and 0.05 mg/kg neostigmine. At the end, thepatients were extubated and transferred to the post anesthetic care unit. In the recoveryroom, oxygen 5 Lit / min with simple mask was administered, and patients were monitored bypulse oxymetry. The patients were maintained in recovery at least an hour. Postoperativepain was determined by the VAS for up to six-hour intervals: during extubation, 15 minutes,30 minutes, one hour, two hours, three hours, four hours, five hours, and six hours afterthe extubation, and if the Visual Analog Scale (VAS) was more than 3, 0.1mg/kg morphine wasadministered intravenously. Total intravenous morphine consumption after the operation, theVAS and the side effects such as nausea, vomiting, laryngospasm and sedation were recordedat the time. Persons responsible for medication and follow-up in patients during and afterthe operations were unaware of the type of primary drug administered to the patient. Alldata were analyzed using the SPSS for Windows (version 12.0). The results of this study werecollected and analyzed by independent sample t- test and Chi-square test. The significancelevel was set to P ≤ 0.05.Demographic data in the study including mean age, weight, and duration of operation in thetwo groups showed no statistically significant difference 1)No significant difference for intravenous morphine consumption for the pain control (P =0.24).2)No significant difference for the first morphine requirement (P = 0.698).Comparison of the two groups in mean VAS in In a study conducted in 2010 by Memis and colleagues, they reviewed the effect ofintravenous Paracetamol in reducing opioid consumption, time of extubation, and opioid sideeffects in intubated patients admitted to the ICU. Ultimately, they concluded thatintravenous Paracetamol reduces opioid consumption, the extubation time, and opioid sideeffects, such as nausea, vomiting, and itching . In this


Chronic pain appears to be associated with brain gray matter reduction in areas ascribable to the transmission of pain. The morphological processes underlying these structural changes, probably following functional reorganisation and central plasticity in the brain, remain unclear. The pain in hip osteoarthritis is one of the few chronic pain syndromes which are principally curable. We investigated 20 patients with chronic pain due to unilateral coxarthrosis (mean age 63.25±9.46 (SD) years, 10 female) before hip joint endoprosthetic surgery (pain state) and monitored brain structural changes up to 1 year after surgery: 6–8 weeks, 12–18 weeks and 10–14 month when completely pain free. Patients with chronic pain due to unilateral coxarthrosis had significantly less gray matter compared to controls in the anterior cingulate cortex (ACC), insular cortex and operculum, dorsolateral prefrontal cortex (DLPFC) and orbitofrontal cortex. These regions function as multi-integrative structures during the experience and the anticipation of pain. When the patients were pain free after recovery from endoprosthetic surgery, a gray matter increase in nearly the same areas was found. We also found a progressive increase of brain gray matter in the premotor cortex and the supplementary motor area (SMA). We conclude that gray matter abnormalities in chronic pain are not the cause, but secondary to the disease and are at least in part due to changes in motor function and bodily integration. Evidence of functional and structural reorganization in chronic pain patients support the idea that chronic pain should not only be conceptualized as an altered functional state, but also as a consequence of functional and structural brain plasticity It is not understood why only a relatively small proportion of humans develop a chronic pain syndrome, considering that pain is a universal experience. The question arises whether in some humans a structural difference in central pain transmitting systems may act as a diathesis for chronic pain. Gray matter changes in phantom pain due to amputation The patients reported here are a subgroup of 20 patients out of 32 patients published recently who were compared to an age- and gender-matched healthy control group We collected data on depression, somatization, anxiety, pain and physical and mental health in all patients and all four time points using the following standardized questionnaires: Beck Depression Inventory (BDI) voxel size 1×1×1 mm).High-resolution MR scanning was performed on a 3T MRI system (Siemens Trio) with a standard 12-channel head coil. For each of the four time points, scan I (between 1 day and 3 month before endoprosthetic surgery), scan II (6 to 8 weeks after surgery), scan III (12 to 18 weeks after surgery) and scan IV (10–14 months after surgery), a T1 weighted structural MRI was acquired for each patient using a 3D-FLASH sequence , we also used VBM8.Data pre-processing and analysis were performed with SPM2  running under Matlab  and containing a voxel-based morphometry (VBM)-toolbox for longitudinal data, that is based on high resolution structural 3D MR images and allows for applying voxel-wise statistics to detect regional differences in gray matter density or volumes a priory hypothesis, which is based on 9 independent studies and cohorts showing decreases in gray matter in chronic pain patients We used a two-sample t-test in order to detect regional differences in brain gray matter between groups (patients at time point scan I (chronic pain) and healthy controls). We applied a threshold of p<0.001 (uncorrected) across the whole brain because of our strong To detect differences between time points (Scan I–IV) we compared the scans before surgery (pain state) and again 6–8 and 12–18 weeks and 10–14 months after endoprosthetic surgery (pain free) as repeated measure ANOVA. Because any brain changes due to chronic pain may need some time to recede following operation and cessation of pain and because of the post surgery pain the patients reported, we compared in the longitudinal analysis scan I and II with scan III and IV. For detecting changes that are not closely linked to pain, we also looked for progressive changes over all time intervals. We flipped the brains of patients with OA of the left hip (n = 7) in order to normalize for the side of the pain for both, the group comparison and the longitudinal analysis, but primarily analysed the unflipped data. We used the BDI score as a covariate in the model.All patients reported chronic hip pain before surgery and were pain free (regarding this chronic pain) immediately after surgery, but reported rather acute post-surgery pain on scan II which was different from the pain due to osteoarthritis. The mental health score of the SF-36 (F(1.925/17.322) = 0.352, p = 0.7) and the BSI global score GSI (F(1.706/27.302) = 3.189, p = 0.064) showed no changes over the time course and no mental co-morbidity. None of the controls reported any acute or chronic pain and none showed any symptoms of depression or physical/mental disability.Before surgery, some patients showed mild to moderate depressive symptoms in BDI scores that significantly decreased on scan III (t(17) = 2.317, p = 0.033) and IV (t(16) = 2.132, p = 0.049). Additionally, the SES scores (pain unpleasantness) of all patients improved significantly from scan I (before the surgery) to scan II (t(16) = 4.676, p<0.001), scan III (t(14) = 4.760, p<0.001) and scan IV (t(14) = 4.981, p<0.001, 1 year after surgery) as pain unpleasantness decreased with pain intensity. The pain rating on scan 1 and 2 were positive, the same rating on day 3 and 4 negative. The SES only describes the quality of perceived pain. It was therefore positive on day 1 and 2 (mean 19.6 on day 1 and 13.5 on day 2) and negative (n.a.) on day 3 & 4. However, some patients did not understand this procedure and used the SES as a global “quality of life” measure. This is why all patients were asked on the same day individually and by the same person regarding pain occurrence.Physical Health Score and a Mental Health Scorethe Physical Health score from scan I to scan II (t(17) = −4.266, p = 0.001), scan III (t(16) = −8.584, p<0.001) and IV (t(12) = −7.148, p<0.001), but not in the Mental Health Score. The results of the NHP were similar, in the subscale “pain” (reversed polarity) we observed a significant change from scan I to scan II (t(14) = −5.674, p<0.001, scan III (t(12) = −7.040, p<0.001 and scan IV (t(10) = −3.258, p = 0.009). We also found a significant increase in the subscale “physical mobility” from scan I to scan III (t(12) = −3.974, p = 0.002) and scan IV (t(10) = −2.511, p = 0.031). There was no significant change between scan I and scan II (six weeks after surgery).In the short form health survey (SF-36), which consists of the summary measures of a We included age as a covariate in the general linear model and found no age confounds. Compared to sex and age matched controls, patients with primary hip OA (n = 20) showed pre-operatively (Scan I) reduced gray matter in the anterior cingulate cortex (ACC), the insular cortex, operculum, dorsolateral prefrontal cortex (DLPFC), right temporal pole and cerebellum . Except Flipping the data of patients with left hip OA (n = 7) and comparing them with healthy controls did not change the results significantly, but for a decrease in the thalamus  and an increase in the right cerebellum  that did not reach significance in the unflipped data of the patients compared to controls.In the longitudinal analysis, a significant increase (p<.001 uncorrected) of gray matter was detected by comparing the first and second scan (chronic pain/post-surgery pain) with the third and fourth scan (pain free) in the ACC, insular cortex, cerebellum and pars orbitalis in the patients with OA . Gray maFlipping the data of patients with left hip OA (n = 7) did not change the results significantly, but for a decrease of brain gray matter in the Heschl’s Gyrus  and Precuneus .By contrasting the first scan (presurgery) with scans 3+4 (postsurgery), we found an increase of gray matter in the frontal cortex and motor cortex (p<0.001 uncorrected). We note that this contrast is less stringent as we have now less scans per condition (pain vs. non-pain). When we lower the threshold we repeat what we have found using contrast of 1+2 vs. 3+4.http://dbm.neuro.uni-jena.de/vbm/) we could replicate this finding in the anterior and mid-cingulate cortex and both anterior insulae.By looking for areas that increase over all time intervals, we found changes of brain gray matter in motor areas (area 6) in patients with coxarthrosis following total hip replacement (scan I<scan II<scan III<scan IV)). Adding the BDI scores as a covariate did not change the results. Using the recently available software tool VBM8 including DARTEL normalisation  yielded a Cohen’s d of 1.78751 in the peak voxel of the ACC . We also calculated Cohen’s d for the longitudinal analysis (contrasting scan 1+2 vs. scan 3+4). This resulted in a Cohen’s d of 1.1158 in the ACC . Regarding the insula  and related to the same contrast, Cohen’s d is 1.0949. Additionally, we calculated the mean of the non-zero voxel values of the Cohen’s d map within the ROI : 1.251223.Monitoring whole brain structure over time, we confirm and expand our pilot data published recently Interestingly, we observed that the gray matter decrease in the ACC in chronic pain patients before surgery seems to continue 6 weeks after surgery (scan II) and only increases towards scan III and IV, possibly due to post-surgery pain, or decrease in motor function. This is in line with the behavioural data of the physical mobility score included in the NHP, which post-operatively did not show any significant change at time point II but significantly increased towards scan III and IV. Of note, our patients reported no pain in the hip after surgery, but experienced post-surgery pain in surrounding muscles and skin which was perceived very differently by patients. However, as patients still reported some pain at scan II, we also contrasted the first scan (pre-surgery) with scans III+IV (post-surgery), revealing an increase of gray matter in the frontal cortex and motor cortex. We note that this contrast is less stringent because of less scans per condition (pain vs. non-pain). When we lowered the threshold we repeat what we have found using contrast of I+II vs. III+IV.Our data strongly suggest that gray matter alterations in chronic pain patients, which are usually found in areas involved in supraspinal nociceptive processing We note that we can only make limited conclusions regarding the dynamics of morphological brain changes over time. The reason is that when we designed this study in 2007 and scanned in 2008 and 2009, it was not known whether structural changes would occur at all and for reasons of feasibility we chose the scan dates and time frames as described here. One could argue that the gray matter changes in time, which we describe for the patient group, might have happened in the control group as well (time effect). However, any changes due to aging, if at all, would be expected to be a decrease in volume. Given our a priori hypothesis, based on 9 independent studies and cohorts showing decreases in gray matter in chronic pain patients In addition to the impact of the nociceptive aspect of pain on brain gray matter Two recent pilot studies focussed on hip replacement therapy in osteoarthritis patients, the only chronic pain syndrome which is principally curable with total hip replacement Another important factor which may bias our interpretation of the results is the fact that nearly all patients with chronic pain took medications against pain, which they stopped when they were pain free. One could argue that NSAIDs such as diclofenac or ibuprofen have some effects on neural systems and the same holds true for opioids, antiepileptics and antidepressants, medications which are frequently used in chronic pain therapy. The impact of pain killers and other medications on morphometric findings may well be important (48). No study so far has shown effects of pain medication on brain morphology but several papers found that changes in brain structure in chronic pain patients are neither solely explained by pain related inactivity We also found decreases of gray matter in the longitudinal analysis, possibly due to reorganisation processes that accompany changes in motor function and pain perception. There is little information available about longitudinal changes in brain gray matter in pain conditions, for this reason we have no hypothesis for a gray matter decrease in these areas after the operation. Teutsch et al. Although this study is an extension of our previous study expanding the follow-up data to 12 months and investigating more patients, our principle finding that morphometric brain changes in chronic pain are reversible is rather subtle. The effect sizes are small (see above) and the effects are partly driven by a further reduction of regional brain gray matter volume at the time-point of scan 2. When we exclude the data from scan 2 (directly after the operation) only significant increases in brain gray matter for motor cortex and frontal cortex survive a threshold of p<0.001 uncorrected .It is not possible to distinguish to what extent the structural alterations we observed are due to changes in nociceptive input, changes in motor function or medication consumption or changes in well-being as such. Masking the group contrasts of the first and last scan with each other revealed much less differences than expected. Presumably, brain alterations due to chronic pain with all consequences are developing over quite a long time course and may also need some time to revert. Nevertheless, these results reveal processes of reorganisation, strongly suggesting that chronic nociceptive input and motor impairment in these patients leads to altered processing in cortical regions and consequently structural brain changes which are in principle reversible.


The aim of this study was to determine whether the dry needling ofmyofascial trigger points (MTrPs) is superior to placebo in theprevention of pain after total knee arthroplasty. Forty subjectswere randomised to a true dry needling group (T) or to a shamgroup (S). All were examined for MTrPs by an experienced physicaltherapist 4–5 hours before surgery. Immediately followinganesthesiology and before surgery started, subjects in the T groupwere dry needled in all previously diagnosed MTrPs, while the S groupreceived no treatment in their MTrPs. Subjects were blinded togroup allocation as well as the examiner in presurgical andfollow-up examinations performed 1, 3, and 6 months afterarthroplasty. Subjects in the T group had less pain afterintervention, with statistically significant differences in thevariation rate of the visual analogue scale (VAS) measurements 1 month after intervention andin the need for immediate postsurgery analgesics. Differenceswere not significant at 3- and 6-month follow-up examinations. Inconclusion, a single dry needling treatment of MTrP underanaesthesia reduced pain in the first month after kneearthroplasty, when pain was the most severe. Results show asuperiority of dry needling versus placebo. An interesting novelplacebo methodology for dry needling, with a real blindingprocedure, is presented. Myofascial pain syndrome (MPS) is a highly prevalent pain condition , 2 causeSteinbrocker is usually quoted as the first to describe the effectiveness of punctures without the injection for pain management . Since tAll available reviews about the effectiveness of dry needling –13 reachSome studies claimed to have used a double-blinded, placebo-controlled methodology with placebo needles for the sham needling group, but they elicited local twitch responses in the intervention group without actually assessing the blinding procedure . A localTo avoid these biases, we conducted a randomized, double-blinded, placebo-controlled clinical trial about the effectiveness of MTrPs dry needling in the prevention of myofascial pain after total knee replacement, using a novel blinding methodology.Total knee arthroplasty has shown to be an effective treatment for knee pain due to knee osteoarthritis, providing patients with improvements in function and in quality of life with low complication rates . It has MTrPs are common in lower limb muscles in patients with hip and/or knee osteoarthritis , and sevThe aim of this study was to find out whether dry needling of MTrPs is superior to placebo in the prevention of pain after total knee arthroplasty, using a novel blinding methodology.Complejo Hospitalario de Toledo (Spain) approved the study protocol. All subjects were interviewed individually to provide them with details about the nature of the study. All subjects voluntarily signed consent forms prior to entering the study.The study was designed as a randomized, double-blinded, placebo-controlled clinical trial. The Ethical and Clinical Research Committee of Forty subjects were recruited between January 2007 and April 2008. To be included in the study, all subjects had to fulfil these criteria: (1) diagnosis of knee osteoarthritis and scheduled for total knee replacement surgery; (2) presence of active or latent MTrPs in at least one of the muscles included in the examination protocol. Patients were excluded from the study if they (1) suffered from any other condition that could cause myofascial or neuropathic pain in the lower limb, such as lumbar radiculopathy, saphenous nerve entrapment, or meralgia paresthetica; (2) presented any condition usually considered a perpetuating factor of MTrPs, such as fibromyalgia, hypothyroidism, or iron deficiencies . There wThe study was carried out between January 2007 and October 2008. An experienced and trained physical therapist, blinded to the group allocation, examined the subjects several hours before surgery and at months 1, 3, and 6 after surgery. Subjects were assigned to a true dry needling group (T) or to a sham dry needling group (S) by using a computerized randomization list .Immediately after each subject was anesthetized and right before surgery started, a trained and experienced physical therapist applied dry needling to all MTrPs previously identified in the T group, using Hong's fast-in, fast-out technique , 28 withThe pain visual analogue scale (VAS)  was the During all checkpoints , subjects were assessed using all these outcome measures, except for the use of analgesic.The VAS consisted of a 100 mm line with the endpoints “no pain” and “worst pain imaginable”. Two days after surgery, the use of analgesic medications was recorded for a period of 4 days. Note that during the first two days, all subjects received intravenously applied analgesics consistent with the hospital's standard protocol.Several hours before surgery, subjects were examined by an experienced physical therapist for the presence of active or latent MTrPs in the muscles of the involved lower extremity using the criteria described by Simons et al. . The tenIn order to establish the prevalence of MPS, patients were considered to suffer from this syndrome if they had at least one active (pain generating) MTrP .The WOMAC is the most widely used instrument to evaluate the symptomatology and function in osteoarthritis of the knee . It contt-test . The averages were compared using a Student's t-test. If any of the conditions required for its application was not fulfilled , the Mann-Whitney U test was used. For the proportions we used Pearson's chi-square test to compare treatment groups and the McNemar test to explore change between time points of study. In order to compare variation rate, Student's t-test was used. The Pearson product-moment correlation coefficient was used. To adjust for potential confounding variables, we employed multivariate models (multiple linear regression and multiple logistic regression).To assess comparability of the groups at baseline, we used chi-square test  and Student's P value was lower than 0.05. The data were analysed using the Statistical Package for the Social Sciences 19.0 (SPSS).We rejected the one-tailed null hypotheses when the No complications related to the dry needling intervention were observed in the T group.P ≥ 0.05) in all characteristics (P = 0.013).Forty volunteers who were to undergo a total knee replacement procedure participated in the study . The mean (SD) age, height, and weight of the subjects were 72.27 (6.95) years, 1.56 (0.08) m, and 74.75 (10.61) kg, respectively. The rate of women in the whole sample was 70% (55% in the T group and 90% in the S group). The involved knee was the right knee in 60% of subjects (55% in the T group and 65% in the S group). 70% of subjects received general anaesthesia (75% in the T group and 65% in the S group), and in the remaining, 30% spinal anaesthesia was used. The groups were not significantly different .Since the baseline values of the VAS were higher in the T group, we analysed the variation rate /baseline value) × 100). The mean value of the variation rate was higher in the T group (−54.50 (56.60) versus −30.47 (63.23) in the S group), and the difference, analysed with Student's P < 0.05).A VAS score greater than 40 is considered to represent a significant level of pain . The anaWhen comparing the outcomes of VAS and VAS > 40 in our study with previously reported results of the natural history of pain after a total knee arthroplasty , the resAll subjects had pain before the intervention. In order to find out the percentage of subjects that were pain-free in the different follow-up examinations, variable VAS = 0 was coded and analysed . The anaSince there were statistically significant differences between groups regarding gender, a multivariate analysis was made (a multiple regression for VAS and a logistic regression for VAS > 40 and VAS = 0) to adjust the effect of the intervention on VAS changes by gender. The inclusion of gender in the analysis did not modify the results in any of the variables. Other variables such as age, BMI, type of anesthesia, and baseline values of WOMAC questionnaire were also included in the multivariate model (not shown here) with no changes observed in significance. Therefore, we did not find any variable that was biasing the results of the analysis.P = 0.01).The use of analgesic medication was significantly lower in the T group (31.8%) than in the S group (68.2%) using a chi-Square test (P = 0.06).Patients are considered to suffer from MPS if they have at least one active (pain generating) MTrP . In our MTrPs are persistent sources of peripheral nociceptive inputs, responsible for peripheral , and cenFor all items on the WOMAC, the T group was worse at baseline and throughout all the follow-up checkpoints. Differences between groups were not statistically significant . The resNo differences between groups were found regarding results in range of motion or strength in any of the follow-up visits. In normal conditions, the rapid needle insertion technique employed in the T group usually elicits brief contractions (LTRs) of the taut band that harbours the MTrP . LTRs arThe main drawback of this study is the small sample size, which together with the lack of a prior power calculation may have caused type II errors.The main objective of our study was to compare the effect of MTrP dry needling versus placebo. Nevertheless, our design does not allow differentiating the effect of MTrP dry needling from the possible neuromodulating effect of the needling itself. Further studies could address this issue using a control group in which needling of the muscle outside the MTrP was applied.A single, brief, and safe dry needling treatment applied under anaesthesia in lower limb MTrPs reduced the pain in the first month after total knee replacement surgery, when pain is highest. Dry needling of MTrPs in the lower limb allowed patients to reach the same degree of pain reduction in 1-month as the subjects with a natural history or placebo intervention achieved in 6-months. It significantly decreased the need for postsurgical analgesia. This study demonstrates that dry needling is superior to placebo in controlling myofascial pain after a knee arthroplasty. The study introduced a novel placebo methodology for dry needling with a real blinding procedure, which could be utilized in similar studies with different co-morbid conditions, or in studies of myofascial pain concomitant with other surgical conditions of other joints so as to avoid the possible interference of the surgical treatment with the intervention on MTrPs.Since a single treatment of MTrPs within the context of a knee replacement surgery has proven to be effective in pain reduction after the intervention, it could be conceivable that a more complete treatment program of MTrPs, either before or after the surgery, could be of great help to reduce pain in these patients. Research is needed to test this hypothesis.