Background. Postoperative pain management remains a significant challenge for all healthcare providers. A randomized controlled trial was conducted to examine the adjuvant effects of auricular acupressure on relieving postoperative pain and improving the passive range of motion in patients with total knee replacement (TKR). Method. Sixty-two patients who had undergone a TKR were randomly assigned to the acupressure group and the sham control group. The intervention was delivered three times a day for 3 days. A visual analog scale (VAS) and the Short-Form McGill Pain Questionnaire were used to assess pain intensity. Pain medication consumption was recorded, and the knee motion was measured using a goniometer. Results. The patients experienced a moderately severe level of pain postoperatively (VAS 58.66 ± 20.35) while being on the routine PCA. No differences were found in pain scores between the groups at all points. However, analgesic drug usage in the acupressure group patients was significantly lower than in the sham control group (P < 0.05), controlling for BMI, age, and pain score. On the 3rd day after surgery, the passive knee motion in the acupressure group patients was significantly better than in the sham control group patients (P < 0.05), controlling for BMI. Conclusion. The application of auricular acupressure at specific therapeutic points significantly reduces the opioid analgesia requirement and improves the knee motion in patients with TKR. Knee osteoarthritis frequently occurs in elderly people. The overall prevalence of knee osteoarthritis is 23.9%, occurring in 21.0% of men and 27.3% of women [Despite the development of new pain control methods and medication and the adoption of guidelines for pain care by many hospitals, postoperative pain is still a problem for many patients. A substantial proportion of total knee replacement (TKR) patients experience severe postoperative pain during the early recovery period . ImpropeGenerally, the clinical management of postoperative pain following TKR mainly involves the use of opioids through patient-controlled analgesia (PCA) to provide the patient with satisfactory pain relief . Given tUsing auricular acupuncture to reduce postoperative pain is promising but not compelling based on a systematic review . AuriculAuricular acupressure is similar to acupuncture, but to our knowledge, there had been no randomized controlled trial (RCT) assessing the effectiveness of auricular acupressure for pain management after TKR surgery. Moreover, routine acupuncture in a clinical setting has its limitations. First, many hospitals are not equipped with an acupuncturist or related resources. Second, the cost for acupuncture is expensive for many patients. Auricular acupressure is a noninvasive intervention and requires less technical expertise. In addition, it may be more acceptable to patients compared with acupuncture. Hence, this study aimed to examine the adjuvant effects of auricular acupressure on reducing analgesic drug requests and improving the range of motion in the knee in postoperative patients after total knee replacement.Ethical approval was obtained from the Hospital Authority of Taiwan and the National University of Nursing and Health Sciences. Sixty-two patients scheduled to undergo an elective total knee replacement were recruited from August 1st, 2010 to March 31, 2011. The inclusion criteria were the following: (i) degenerative arthritis and having total knee replacement surgery, (ii) use of patient-controlled analgesia (PCA) after surgery and an American Society of Anesthesiologist physical status of Classes I–III, (iii) ability to communicate in Taiwanese or Mandarin, and (iv) agreement to participate in this study.Patients were excluded if they suffered from pain or injuries in the ears, had a history of neurological disorders that could alter their perception of pain, a prior experience with auriculotherapy, malignant tumors, a serious chronic illness, mental illness, or drug/alcohol addiction, or were unable to give consent or follow instructions during the data collection process.All of the patients received an operation under standardized general anesthesia protocols. The patients received routine pain management at the end of the operation: the intravenous PCA was connected to an IV line and set to deliver a bolus of 1 mg morphine with a lockout interval of 5 minutes and a 4-hour maximum morphine dose of 10 mg.Patients who met the study criteria were interviewed by the investigator before the operation; the purposes of the study were explained, and written consent to participate in the study was then obtained. Throughout the study period, one acupressure therapist performed the auricular acupressure, and the outcome data were collected by a research assistant who had been trained and was blinded to the patient's group. The physicians, anesthesiologists, and nurses had no previous knowledge of acupressure and were blinded to the patients' group allocation. The data collection processes are shown in The study, which was conducted at a regional teaching hospital in central Taiwan, used a sham control group and double-blinded experimental design. Sixty-two patients were recruited in our study during an eight-month period. Based on computer-generated codes, block randomization was used with a block size of 4. The patients were randomly assigned into the auricular acupressure or sham control groups. The auricular acupressure therapy was delivered by the therapist, who was an advanced practice nurse and had been accredited for practicing acupressure. The auricular acupressure involved embedding the magnetic beads within skin-colored adhesive tape that was placed on the auricular acupoints and retained in situ for 3 days . The choThe patients in the sham control group received regular care and also received the same skin-colored adhesive tape placed on the acupoints but did not receive any massage or acupressure. The sham control patients were given auricular acupressure after the data collection was completed.f of 0.84, an α error probability of 0.05 and data collection performed in triplicate, a sample size of 62 would achieve statistical power up to 0.90.The sample size was estimated based on the data of the pilot study. With an effect size α was 0.83 in this study.The pain assessment was conducted using the visual analog scale (VAS) and the Short-Form McGill Pain Questionnaire (SF-MPQ), both of which have good reliability . The VASα range, 0.78 to 0.83) [α was 0.76 in this study.The SF-MPQ was modified from the MPQ by Melzack in 1987 . The scato 0.83) . CronbacThe range of motion is measured with the flexion mobility of the knee at day 3 after the surgery using the goniometer integrated in the dynamometer . Non-weit-test, χ2, or one-way analysis of variance (ANOVA). A generalized estimation equation (GEE) modeling was applied to investigate the effect of auricular acupressure for the outcomes of pain and opioid consumption. A t-test was used to compare differences in knee motion between the acupressure and sham control groups. A P value of less than 0.05 was considered to indicate statistical significance.Data management and analyses were conducted using the SPSS for Windows statistical package, version 17.0. The patients' demographic profiles and baseline data were compared using the P > .05)  years. The operations included 31 left knees and 31 right knees and were performed by 2 surgeons. There were no differences between the acupressure and sham control groups in terms of the demographic and clinical characteristic data obtained at the baseline  . None ofP > .05).The descriptive data of the postoperative pain scores (VAS-pain and Short-form McGill Pain Questionnaire) reported by the patients are shown in P < 0.05). Additionally, after controlling for BMI, age, and pain scores (VAS) in the generalized estimated equation model analysis, analgesic drug consumption in the acupressure group patients remains significantly lower than in the sham control group (P = .002) patients over time  usage of the patients are summarized in ver time . The dosP = .01). The results of Pearson's correlation analysis found a negative correlation between the knee flexion motion and BMI (P < 0.05). Therefore, further regression analysis was conducted, and after controlling for BMI, the results remained significant between the groups (P = .02).On the 3rd day after surgery, the passive knee flexion motion in the acupressure group patients (71.68 ± 6.90°) was significantly better than in the sham control group patients (66.94 ± 7.15°) (Our patients reported postoperative pain as moderately severe during the 1st day (baseline) following TKR while the patients were on PCA for pain management. This result corresponded with previously reported results , who repSimilar to acupuncture, we found that 3 days of auricular acupressure can significantly lower the postoperative opioid consumption after a total knee replacement surgery. Our results showed that the morphine consumption in the sham control group patients was 8.38 times higher than that in the acupressure group. This finding is consistent with that of previous studies, which showed that auricular acupuncture is effective in managing postoperative pain , 15. UsiThe analgesic effect of acupressure in the reduction of required postoperative morphine can most likely be explained through the stimulation of acupoints, which can adjust organs, correct imbalances of Qi, stabilize the body, strengthen the functions, and cure diseases . AcupoinOur present findings illustrate that auricular acupressure applied to the Shenmen (TF4) and Subcortex (AT4) acupoints can also improve the range of motion of the knee after the operation. This effect can be explained primarily because auricular acupressure produced an analgesic effect, allowing patients to have a better compliance with the treatments designed to improve the range motion in the knee. A literature search revealed no acupressure studies and only one acupuncture study in a TKR population. Tsang et al. concluded that acupuncture was no better than sham acupuncture in pain relief and in improving the range of knee motion in patients who had undergone bilateral total knee arthroplasty . NeverthThe acupressure procedure was safe and easy to perform under the perioperative clinical conditions using finger press and massage on the auricular acupoints after the operation. The study protocol was based on the experts' recommendations for the practice of acupuncture. Although the randomization in the groups was successful as indicated by the balance regarding age, gender, and BMI, which can confound the postoperative analgesic requirement, we improved the control over BMI in the statistical analysis to increase the validity of our results. Our double-blinded study design minimized the potential biases. The blinding of patients and data collectors was adequate, which strengthened the credibility of the main result.We selected a randomized sham control design and used adhesive tape on the acupoints as the sham control. We also provided acupressure to the sham control group patients at the end of this study. With this design, all participants eventually received the therapeutic auricular acupressure. Our design may avoid the ethical dilemma of withholding a potentially helpful treatment for half of the participants. Noticeably, our study had no actual placebo group for comparing the study effects. According to TCM theory, the body contains 14 meridians  that bear countless branches . As the theory notes, finding a body site without the influence of any Jing and Luo would be difficult. Considering that most of the meridians are densely distributed, especially in the ear, massage anywhere on the body can produce the same therapeutic effect . ConsequA potential limitation of our research is that those who chose to be involved in the trial were limited to one hospital, and the findings may therefore not be indicative of the changes likely to occur with the general TKR population. Furthermore, the followup period of 3 days after the TKR surgery was short, and we have no way to determine the long-term effects of auricular acupressure. Furthermore, the dose of acupressure may have been inadequate; for example, more frequent treatments or a different treatment protocol may have generated different results. Given that reasonable evidence on the course effectiveness has been established in the current study, further research should focus on longer-term followup and collecting data from multiple centers to determine whether the changes and positive effects of acupressure are maintained over time. In conclusion, a program of auricular acupressure applied to therapeutic auricular acupoints significantly reduces the opioid analgesic consumption and improves the passive range motion of the knee postoperatively after total knee replacement. However, both groups of patients experienced a similar degree of pain, based on their reported scores, while on the routine PCA for pain management.


The treatment for thoracolumbar burst fractures is controversial. The aim of this retrospective study was to compare intermediate-segment (IS) and long-segment (LS) instrumentation in the treatment for these fractures.IS instrumentation was considered as pedicle fixation two levels above and one level below the fractured vertebra (infra-laminar hooks attached to lower vertebra with pedicle screws). LS instrumentation was done two levels above and two levels below the fractured vertebra. Among a total of 25 consecutive patients, Group 1 included ten patients treated by IS pedicle fixation, whereas Group 2 included fifteen patients treated by LS instrumentation.p = 0.955), sagittal index (p = 0.128), anterior vertebral height compression (p = 0.230) and canal diameter expansion (p = 0.839) demonstrated similar improvement at the final follow-up between the two groups. However, there was a significant difference (p < 0.05) between Group 1 and Group 2 regarding clinical outcome .The measurements of local kyphosis (The radiographic parameters were the same between the two groups. However, the clinical parameters demonstrated that IS instrumentation is a more effective management of thoracolumbar burst fractures. Unstable fractures of the thoracolumbar spine often require internal fixation. Stabilisation of these injuries has many advantages, including early mobilisation of the patient and the potential for neurological improvement. The optimal treatment for these injuries is controversial.The treatment modality that provides superior spinal canal restoration has not yet been conclusively identified , 2. VariShort-segment posterior instrumentation is currently the most frequently used treatment modality , 6, 7. MThe aim of this study was to evaluate and compare the radiological and functional results between intermediate-segment (IS) instrumentation and long-segment (LS) instrumentation via a posterior approach in the treatment of thoracolumbar burst fractures.In this study, 37 out of 50 patients who had been surgically treated by a single surgeon for thoracolumbar vertebra fractures between 2000 and 2009 were evaluated. Four patients were eliminated from the study because they developed neurological deficits, and eight patients were excluded from the study because they did not return for control visits, although they were invited. A total of 25 patients  were retrospectively evaluated. Fourteen out of 25 patients had a type B fresh thoracolumbar burst fracture according to the Denis classification at L1, seven at T12 and four at L2 [Urgent decompression and vertebral alignment are required in the presence of neurological deficits. While some authors recommend the surgery when the patient is stable, some others prefer to wait for 4 days or longer until post-traumatic swelling decreases. All of our patients were operated on within the first 24 h after injury. A posterior approach to the thoracolumbar vertebrae is a well-described and accepted surgical procedure.Posterior instrumentation with fusion was used for vertebral surgery in our clinic. Adequate surgical exposure was performed via posterior midline incision. Pedicle screws were placed in accordance with surgical technique. If 2–1 instrumentation was performed, four trans-pedicular screws were inserted into the two vertebrae cranial to the fractured vertebra, two trans-pedicular screws were inserted into the one vertebra caudal to the fractured vertebra, and two laminar hooks were inserted into both laminae of the same vertebra on the caudal side , sagittal index and local kyphosis angle (LKA) with preoperative, post-operative and follow-up radiographs. Anterior corpus height decompression was calculated using the formula described by Mumford et al. . The locp value of <0.05 was accepted as statistically significant.Hannover vertebra scores , the OswThe mean duration between injury and surgery was 24 h. The patients were discharged from the hospital in an average of 6.3 days. The mean duration of follow-up was 72.3 months in the IS instrumentation group and 70.46 months in the LS instrumentation group.p = 0.128). The mean anterior corpus height compression decreased from 36.10 % preoperatively to 12.10 % post-operatively and then increased to 18.80 % at follow-up in the IS instrumentation group. The mean anterior corpus height compression decreased from 34.45 % preoperatively to 11.33 % post-operatively and then increased to 15.63 % on follow-up radiographs in the LS instrumentation group. While the mean LKA measured 15.30° preoperatively in the IS instrumentation group and 9.62° in the LS instrumentation group, it was reduced to 1.20° in the IS instrumentation group and 0.30° in the LS instrumentation group post-operatively. On follow-up radiographs, the LKA measured 3.15° in both groups. Statistically significant differences were not found in ACHC or LKA, and the reductions in the degree of correction were also statistically insignificant (p = 0.230 for ACHC and p = 0.955 for LKA).While the mean sagittal index was 12.84 preoperatively in the IS instrumentation group, it was reduced to −1.01 post-operatively and then increased to 1.9 on final follow-up radiographs. The sagittal index measured 12.13 preoperatively, −1.01 post-operatively and 1.54 on follow-up radiographs in the LS instrumentation group. Although there was no significant difference between the two groups in terms of sagittal index, preoperative, post-operative and late post-operative follow-up results significantly differed between the two groups (p = 0.839).When the diameter of spinal measured preoperatively was compared to post-operative measurements in the long term, the diameter of the spinal canal in the long term post-operatively increased by 48.56 % in group 1 and by 47.01 % in group 2 patients compared to preoperative measurements. The difference between the IS and LS groups was not statistically significant (p = 0.07).Hannover vertebra scoring and the Oswestry Disability Index for the assessment of functionality were completed for all patients. The mean Hannover vertebra score was 82 (70–85) in the LS instrumentation group and 62.1 (28–85) in the LS instrumentation group. The mean Oswestry disability score among the ten patients who underwent IS instrumentation was 14.4 % (12–24 %), and the mean Oswestry disability score of the 15 patients who underwent LS instrumentation was 29.2 % (12–58 %). In the IS instrumentation group, eight cases (80 %) reported low disability, two cases (20 %) reported moderate disability, and there were no reports on severe disability. In the LS instrumentation group, six cases (40 %) reported low disability, four cases (27 %) reported moderate disability, and five (33 %) reported severe disability. The difference in long-term Hannover vertebra scores of the patients in the IS and LS groups was statistically significant (p < 0.05).Long-term range of motion was compared to neutral (0°). The mean flexion was 66.5°, the extension was 19.5°, the lateral flexion was 20.5°, and the rotation was 30.5° in the IS instrumentation group; in contrast, the mean flexion was 50.5°, the extension was 10.5°, the lateral flexion was 12.5°, and the rotation was 21.5° in the LS group. The difference between the groups was statistically significant  may occur weeks or months after the initial surgery and typically is observed in the strong, dense bone of young trauma patients . AlternaIn the past few years, a new perspective in the treatment of thoracolumbar trauma was offered with the development of minimally invasive techniques. Their objective is to minimise conventional approach morbidity, such as blood loss, iatrogenic muscle trauma, pain and functional deterioration. It has also been suggested as an adjunct to conventional posterior stabilisation, as it can minimise spinal levels requiring fusion . This teAugmentation of the short-segment pedicle instrumentation (SSPI) construct with offset laminar hooks has been recommended as a means of preventing fixation failure in thoracolumbar fractures , 30. TheAdding one level of fixation cranially will increase the construct stiffness. Although adding a single motion segment may artificially increase segmental stiffness, to some extent, the protective benefit to pedicle screw bending moments is real. Finally, the addition of a single motion segment cranial to the fracture does not affect the spinal range of motion or sacrifice the principles of SSPI because the thoracic segments are relatively immobile and do not influence the function of the lower lumbar spine , 31.The clinical implications of our findings are that augmentation of an SSPI construct with sublaminar hooks results in a stronger construct while decreasing the bending moments on the screws that might predispose to device failure. Therefore, addition of sublaminar hooks may decrease the rate of clinical failures with SSPI for unstable thoracolumbar fractures while still maintaining the advantages of this system: minimal fusion length, three-column fixation and application through a posterior approach , 32.Supplemental offset hooks significantly increased construct stiffness without sacrificing the principles of SSPI (limited lumbar fixation). Furthermore, offset hooks absorb some components of the construct strain, thereby reducing the bending moments transmitted to the screws and reducing the likelihood of screw failure in severely unstable fractures .Some surgeons add pedicle screws at the fractured vertebrae, termed intermediate screws, as part of a short-segment construct. These screws theoretically may stiffen the construct by splitting the length of the rod that spans from the upper screw to the lower screw into two half-length parts. A shorter rod between two points of fixation will create increased stiffness, and the additional fixation point can theoretically decrease the motion at the metal–bone interface. Nevertheless, the true mechanical function of screws inserted into a fractured vertebra is unclear, as the pattern of a burst fracture involves comminution of the vertebral body and separation of the pedicles. To the authors’ knowledge, no study has been carried out to show the biomechanical effect of intermediate screws on the fixation of fractures. Dick et al.  evaluateIn conclusion, the addition of supplemental hooks below the fractured vertebra with trans-pedicular screws inserted into the anterior cortex can result in less motion at the fractured segment within a short-segment construct. Short-segment fixation offers the advantage of preserving motion segments in the lumbar spine. The authors recommend the use of supplemental sublaminar hooks when posterior spinal fusion is indicated for the fixation of unstable thoracolumbar fractures.In this study, no statistically significant difference was detected between the groups in terms of long-term functional and radiographic results. Methods supporting anterior column or LS instrumentation are applied to eliminate negative conditions such as the insufficient reduction, reduction loss and inadequate expansion of the spinal canal encountered after short-segment posterior instrumentation , 9, 33. We recommend future research to compare short-segment and long-segment instrumentation for T12 vertebral fracture, L1 vertebral fracture and L2 vertebral fracture individually.


Pain is a major problem in patients after cesarean and medication such as aromatherapywhich is a complementary therapy, in which the essences of the plants oils are used toreduce such undesirable conditions.In this study, the effect of aromatherapy using Lavender (Lavandula) essential oil oncesarean postoperative pain was assessed.In a triple blind, randomized placebo-controlled trial study, 60 pregnant women whowere admitted to a general hospital for cesarean section, were divided randomly into twogroups. After cesarean, the Lavender group inhaled about 3 drops of 10% Lavender oilessence and the placebo group inhaled 3 drops of placebo after the start ofpostoperative pain, four, eight and 12 hours later, for 5 minutes from the 10 cmdistance. Patient's pain was measured by the VAS  score before andafter each intervention, and vital sign, complications and level of satisfaction ofevery patient were recorded before and after aromatherapy.There was no statistically significant difference between groups in age, height,weight, and time to the first analgesic requirement. Patients in the Lavender group hadless postoperative pain in four (P = 0.008), eight (P = 0.024) and 12 (P = 0.011) hoursafter first medication than the placebo group. The decreased heart rate and patients'level of satisfaction with analgesia were significantly higher in the Lavender group (P= 0.001). In the placebo group, the use of diclofenac suppositories for completeanalgesia was also significantly higher than the Lavender group (P = 0.008).The inhaled Lavender essence may be used as a part of the multidisciplinary treatmentof pain after cesarean section, but it is not recommended as the sole painmanagement. Pain is amongst the most common problems after surgery . Pain isCesarean surgery is common, especially in our country, and the patient's postoperative painis a serious problem. Furthermore, the extent of conventional method for the pain relief isa prescription of opioids and NSAIDs, which are also associated with certain complications,and needs additional methods of the pain control, consequently, we decided to assess theeffect of the inhalation aromatherapy using Lavender oil essence on postoperative pain.In a triple blind, randomized placebo-controlled trial, which was performed for the firsttime in Ahvaz, a city located in the south western part of Iran, after approving by AhvazJundishapur University of Medical Sciences (AJUMS) Ethical Committee, 60 pregnant women, whowere admitted to a general hospital for cesarean section, were divided randomly into twogroups. Subjects with pregnancy, ASA class I and II, absence of hypertension, coagulationdisorders, migraines and chronic headaches, no history of allergies to medicinal plants, nohistory of anosmia were included. Subjects with respiratory problems during surgery, nausea,vomiting, sensitivity and dissatisfaction after the first dose of aromatherapy usingLavender oil essence were excluded. The severity of pain was documented based on the VisualAnalog Scale (VAS).The VAS is a standard tool like a 10 cm ruler including 10 numbers beginfrom 0 (no pain) and end to 10 (most severe pain). Different states of a human face inresponse to pain severity have been plotted on the other side of ruler. The patients wereasked to choose one of them according to their pain severity. The number shown on the backof the ruler was considered as pain score. The Lavenders (Lavandula angustifolia) are agenus of several species of flowering plants in the mint family, Lamiaceae. In this study,Lavender essence 10% was provided by the Barij Essence Pharmaceudical Company . Placebo was a base of aromatherapy blend without Lavender essence which was providedby the Barij Essence Pharmaceudical Company too. In the beginning, possible side effects ofdrugs used in the study, were explained to the patients, and after obtaining informedconsent, patients were entered into the operating room. Patients were performed monitoringby ECG (Electrocardiography), monitoring for heart rate recording, NIBP (None Invasive BloodPressure) and Pulseoximetry. After embedding the peripheral intravenous cannula, 500 cc ofRinger's crystalloid fluid was infused for patients. Afterwards, regional block with spinalanesthesia was performed with 60 mg of Lidocaine 5%, and then the patients underwentcesarean section. Opioid or benzodiazepine was not used after cesarean section in operatingroom as sedation. Pain score were measured using the VAS score for all patients. After theonset of postoperative pain (if VAS > 3), four, eight and 12 hours after that, theinhalation aromatherapy was performed using Lavender essence. In one group, three drops ofaromatherapy blend containing Lavender essence 10%  were poured on cotton in cast containers, and the patient was askedto inhale it for 5 minutes from a distance of 10 cm; and pain score was measured using theVAS again, and if the VAS was greater than three, analgesic was given in accordance with thehospital routine protocol . Using the same procedure, aromatherapywas performed in the other group by three drops of placebo (a base of aromatherapy blendwithout Lavender essence) where its smell and appearance were similar to the Lavender oilessence. Heart rate, blood pressure, nausea, vomiting, dizziness, and patient's satisfactionwere recorded before and after the aromatherapy based on the questionnaire. During theresearch, the project executive and the patients were not aware of the type of drug andplacebo, and after the study and data analysis, the Lavender and the placebo were disclosedby the Barij Essence Pharmaceudical Company. All data were analyzed using the SPSS forWindows (version 19.0). Independent T-test was used compare the mean pain in two groups; thePaired t- test was used to compare the pain before and after intervention. The significancelevel was set to P ≤ 0.05.In this study, all patients were ASA class I. At the time of the onset of the pain aftercesarean section, aromatherapy with Lavender essence was performed. Average age, height,weight in the two groups showed no significant difference, and times of need to the firstanalgesic from cesarean section were similar in the two groups . After uAfter using the drug comparing it with before, heart rate showed a greater reduction in theLavender group compared with the placebo group, which has been shown in the table . HoweverThis study investigated the effect of inhaled Lavender essence on the pain relief aftercesarean. The results showed that pain after surgery in four, eight and 12 hours after theonset of symptoms following inhalation of Lavender essence have had a significant decreasecompared with the placebo group. The pain control after cesarean delivery is a greatchallenge for the anesthesiologists and gynecologists, because the spread use of drugs cancause side effects such as nausea, vomiting and excessive sedation; and it can cause a delayin getting out of bed and discharge from the hospital. In addition, the drugs excrete inbreast milk and can cause sedation in baby as well . The use


Platelet activation has been implicated in the pathogenesis of sickle cell disease (SCD) suggesting antiplatelet agents may be therapeutic. To evaluate the safety of prasugrel, a thienopyridine antiplatelet agent, in adult patients with SCD, we conducted a double-blind, randomized, placebo-controlled study.The primary endpoint, safety, was measured by hemorrhagic events requiring medical intervention. Patients were randomized to prasugrel 5 mg daily (n = 41) or placebo (n = 21) for 30 days. Platelet function by VerifyNow® P2Y12 and vasodilator-stimulated phosphoprotein assays at days 10 and 30 were significantly inhibited in prasugrel- compared with placebo-treated SCD patients.There were no hemorrhagic events requiring medical intervention in either study arm. Mean pain rate (percentage of days with pain) and intensity in the prasugrel arm were decreased compared with placebo. However, these decreases did not reach statistical significance. Platelet surface P-selectin and plasma soluble P-selectin, biomarkers of in vivo platelet activation, were significantly reduced in SCD patients receiving prasugrel compared with placebo. In sum, prasugrel was well tolerated and not associated with serious hemorrhagic events.Despite the small size and short duration of this study, there was a decrease in platelet activation biomarkers and a trend toward decreased pain. The clinical manifestations of disease are due to hemolysis, and intermittent microvascular occlusion marked by painful vaso-occlusive crisis (VOC) and eventual end-organ damage from repeated bouts of ischemia-reperfusion injury resulting in significant disabilities and early mortality. SCD pathophysiology is multi-factorial. The reduced intracellular solubility of HbS leads to intra-erythrocytic hemoglobin polymerization and loss of red cell deformability under conditions of hypoxia and acidosis  mean: 42.2% vs. 53.5%) in pain rate and a relative 25% reduction (LS mean: 1.8 vs. 2.4) in pain intensity. However, these differences did not reach statistical significance. An alternative analysis showed that a greater proportion of patients in the prasugrel arm (50%) reported no pain throughout the study (27.5% of patients with a percentage of days with pain = 0) or infrequent pain (22.5% of patients with ≤ 25% of days with pain) versus 22.3% of placebo-treated patients having either no pain (5.6% of patients with a percentage of days with pain = 0) or infrequent pain (16.7% of patients with ≤ 25% of days with pain)  at both day 10 and day 30. About 20% of patients had <20% inhibition, which is consistent with the rate seen with the 5-mg maintenance dose in previous studies [The point-of-care VerifyNow® P2Y12 device and VASP PRI were used to assess prasugrel’s pharmacodynamic effect on platelets. Figure  studies -26. BecaNumerous studies have shown that platelets are activated in SCD patients ,12 and tIn this randomized Phase 2 study of prasugrel in adult patients with various genotypes of SCD in steady state, 30 days of treatment was not associated with hemorrhagic events that required immediate medical attention. As expected for a platelet function inhibitor, there were more hemorrhagic AEs with prasugrel; however, the majority was mild and none resulted in serious adverse events or adverse events leading to study drug or study discontinuation. However, it bears emphasis that exclusion criteria were conservative, enrolled subjects were at low risk for hemorrhage and this pilot study was of short duration.in vivo platelet activation in SCD without producing serious bleeding.Evidence of platelet inhibition was seen amongst prasugrel-treated patients with SCD. Prasugrel treatment resulted in approximately 33% to 40% platelet inhibition as measured by both VerifyNow® P2Y12 and VASP, suggesting that patients with SCD achieved a substantial pharmacodynamic response with prasugrel treatment similar to that seen in previous studies in patients with cardiovascular disease. Despite this effect, it was still possible that the marked hemostatic and inflammatory milieu in SCD patients might have overcome potential inhibition of platelet activation by prasugrel via other platelet activation pathways, such as thrombin generation. However, the decreased levels in cellular and soluble markers of platelet activation observed in the prasugrel-treated group show this agent is able to overcome this platelet pro-stimulatory environment and attenuate Perhaps more provocative is the suggestion that prasugrel may be efficacious in reducing pain. The traditional endpoint for therapeutic efficacy in SCD is the occurrence of acute painful episodes . However, paradigm shifting work by Smith et al. ,28. has It is important to compare and contrast the results of this study to the other published studies of platelet inhibitors in SCD. Osamo et al. examined the effect of aspirin on red cell survival in patients with SCD . Fifty pGreenberg et al. studied somewhat lower doses of aspirin (3–6 mg/kg) for 21 months in 49 children with HbSS, HbSC, or HbSO-Arab in a double-blind cross-over study to prevent acute pain crises . Ninety-Chaplin and colleagues added the phosphodiesterase inhibitor dipyridamole to aspirin as prophylaxis for acute pain crisis . This stPrevious studies have tested the effect of the first generation thienopyridine ticlopidine in SCD patients. Semple and colleagues assessed platelet survival in 9 patients with SCD using radiolabeled platelets and platelet activation by measuring plasma levels of platelet release products . PatientCabannes et al. studied the efficacy of ticlopidine in the prevention of acute pain crisis in 140 patients in Africa . PatientOur study showed similar effects on platelet activation to those demonstrated with ticlopidine, confirming its platelet suppressive effect in this population of patients without provoking clinically serious bleeding. It is important to note that the current Phase 2 study was not powered to find a difference in acute painful episodes. Nonetheless, there was a trend toward decreased number of days with pain. Treatment with prasugrel compared with placebo was associated with numerical decreases in pain rate and pain intensity, as reported in daily patient diaries, and a numerical decrease in pain events related to SCD that required medical attention, as assessed by the study investigator. In adjusted analyses, prasugrel was associated with a 21% relative reduction in the percentage of days with pain and a 25% relative reduction in pain intensity compared with placebo.Although it is clear from the patient pain diaries that the majority of patients had pain at some point during the study and many of the patients randomized to placebo experienced chronic pain, relatively few patients sought medical attention for their pain (27%). From the case report forms, 22.5% of prasugrel-treated patients sought medical attention for a pain event versus 36.8% of placebo-treated patients. These provide a signal that prasugrel may be efficacious in reducing the frequency and severity of VOC in patients with SCD.In summary, the results of this randomized, double-blind, Phase 2 study showed that prasugrel inhibited platelet function, decreased biomarkers of platelet activation, and showed a trend toward decreased pain by several measures without serious hemorrhagic adverse events. However, these results must be interpreted with caution, as measures of pain were not primary outcomes and the duration of this study (30 days) was short. A larger study with a sample size appropriately powered to determine effects on clinically relevant endpoints and provide longer safety analysis is needed to confirm and extend these findings.CZ, LEH, KJW, JSR, and JAJ, Eli Lilly and Company Employment and Equity Ownership. TW, LK, LEM, JJS, Daiichi Sankyo Co., Ltd. and Eli Lilly and Company Research Funding. CEN, Daiichi Sankyo, Inc. Employment and Equity Ownership. AK, Research funding from Novartis, Celgene, Hemaquest, Daiichi Sankyo Co., Ltd., and Eli Lilly and Company. KIA, Adventrx Consultancy, Daiichi Sankyo Co., Ltd. and Eli Lilly and Company Research Funding. ALF, PhD Research funding: Daiichi Sankyo Co., Ltd. and Eli Lilly and Company, GLSynthesis, Glycomimetics; Consultant: Eli Lilly and Company. CLK, DS, EN, no financial relationship(s) to disclose.TW, participated in the design of the study, chaired the study, performed the research, and wrote the manuscript. ALF III performed research (assayed selected biomarkers); contributed to manuscript EN, performed research (contributed patients to the study), contributed to manuscript DS, FRCPC, MSc, performed research (contributed patients to the study), contributed to manuscript. LK, performed research (contributed patients to the study), contributed to manuscript. AK, performed research (contributed patients to the study), contributed to manuscript KA, performed research (contributed patients to the study), contributed to manuscript. CZ MS, participated in the design of the study, analysis and interpretation of the data, contributed to manuscript and performed the statistical analyses. LEH, participated in the design of the study, analysis and interpretation of the data, contributed to manuscript. CEN, participated in the design of the study, contributed to manuscript. JAJ, participated in the design of the study, analysis and interpretation of the data, contributed to manuscript. KJW, participated in the design of the study, analysis and interpretation of the data, contributed to manuscript. JSR, participated in the design of the study, contributed to manuscript. CLK, performed research (contributed patients to the study), assisted with revisions of the manuscript. LEM, Performed research (contributed patients to the study), contributed to manuscript. JJS Performed research (contributed patients to the study), contributed to manuscript. All authors read and approved the final manuscript.


Pain is a common problem for patients admitted to the ICU, causing patient discomfort, agitation and accidental self-extubation. For this reason the recognition of pain and its severity is extremely important. Several pain scores and protocols are in use. We aimed to elucidate current practice of pain measurements and treatment in Dutch ICUs.In March 2011, a questionnaire was sent to all Dutch adult ICUs irrespective of the number of ICU beds with active follow-up by telephone calls to optimize the participation rate.A total of 84 ICUs (84/107) returned the survey, representing a response rate of 87%. Most ICUs are community teaching hospitals and nonteaching hospitals (85%) in comparison to academic hospitals (15%). Most ICUs (94%) use a standardized pain score in the group of patients who are capable of verbal communication: the Visual Analogue Scale (57%), Numerical Rating Scale (48%) and Faces Pain Scale (5%) being the most frequently used scores. In the group of patients who are unable to communicate, ICUs less frequently use pain scores (19%), with the Critical-Care Pain Observation Tool (6%) and Behaviour Pain Scale (5%) being used most frequently. Measurement of pain was considered most important for patients with burn wounds (67%), trauma patients (64%), postoperative patients (57%) and those who receive end-of-life care (64%). Barriers to use pain measurements included the patient's inability to communicate (82%), interference with pain assessment due to sedation (79%), hemodynamic instability (64%), insufficient dosages of analgesics (60%) and the unavailability of a standard pain scoring system (51%). In addition, guidelines for management of sedation and analgesics from the Netherlands Association for Intensive Care (NVIC) had been read by only 20% of the respondents. Factors that were mentioned to be useful in contributing to an improvement in pain assessment and effective pain control included adequate analgesic dosage (87%), utilization of protocols and directives (86%), enthusiastic and motivated personnel (81%) and the utilization of standardized pain measurement tools.Most Dutch ICUs measure pain frequently (94%) in patients who are able to communicate. However, in the group of patients who cannot communicate only 19% of the Dutch ICUs use a standardized pain score. This finding applied to both academic and nonacademic ICUs, which suggests that efforts should be put into implementing pain measures in Dutch ICUs.


Approximately 20% of patients report persistent and disabling pain following total knee arthroplasty (TKA) despite an apparently normally functioning prosthesis. One potential risk factor for unexplained persistent pain is high levels of pain catastrophizing. We designed a three-arm trial to determine if a pain coping skills training program, delivered prior to TKA, effectively reduces function-limiting pain following the procedure in patients with high levels of pain catastrophizing.The trial will be conducted at four University-based sites in the US. A sample of 402 patients with high levels of pain catastrophizing will be randomly assigned to either a pain coping skills training arm, an arthritis education control arm or usual care. Pain coping skills will be delivered by physical therapists trained and supervised by clinical psychologist experts. Arthritis education will be delivered by nurses trained in the delivery of arthritis-related content. The primary outcome will be change in Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) Pain scale score 12 months following surgery. A variety of secondary clinical and economic outcomes also will be evaluated.The trial will be conducted at four University-based sites in the US. A sample of 402 patients with high levels of pain catastrophizing will be randomly assigned to either a pain coping skills training arm, an arthritis education control arm or usual care. Pain coping skills will be delivered by physical therapists trained and supervised by clinical psychologist experts. Arthritis education will be delivered by nurses trained in the delivery of arthritis-related content. The primary outcome will be change in Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) Pain scale score 12 months following surgery. A variety of secondary clinical and economic outcomes also will be evaluated.NCT01620983 Pain is the predominant complaint of patients seeking total knee arthroplasty (TKA)-3, a comSerious early surgical complications such as pulmonary embolism or joint infection lead to poor outcomes. However, the incidence of these adverse events is very low - approximately 2% of all surgeries. Failure of the prosthesis is typically a late complication occurring years following the surgery and accounts for approximately 5% of poor outcomes. The larHowever, some patients respond poorly to the surgery. For example, Puolakka and colleagues found that 36% of 433 patients reported daily disturbing pain four months or more after surgery,18. HawkDisabling pain and reduced function is a large and as yet unsolved problem that has a dramatic impact on quality of life and productivity. For example, revision surgery rates are influenced by persistent pain and impaired function. Roberts and colleagues conducted a survival analysis of 4,400 patients with knee arthroplasty and found that 15 years following surgery, a total of 239 knees required revision and up to 35% were for unexplained pain. Extrapolating to current estimates, as many as 35% of 55,000 revision arthroplasty surgeries in the US in 2010 may be attributable to unexplained persistent pain and subsequent poor function[A barrier to improving postoperative outcomes is that traditionally, knee arthroplasty has been presumed to be a highly effective procedure. TKA perioperative protocols have historically not incorporated routine screening for patients at-risk for post-surgery persistent pain or compromised function because this area has not been scientifically investigated. This culture has strong potential for change, however, because recent research has begun to acknowledge that unexplained poor outcomes occur. Predict, current clinical practice paradigms could be significantly improved.Additional impetus to address the issue of persistent pain was proposed by the National Institutes of Health (NIH). An NIH consensus panel was convened to review existing evidence regarding the use of knee arthroplasty surgery and to make recommendations for future research to improve the care for these patients. The panThe primary aim of our study is to assess the efficacy of a physical therapist-delivered pain coping skills training program in reducing knee pain and improving function. Our two primary hypotheses are that in patients scheduled for knee arthroplasty and with comorbid pain catastrophizing: (1) Pain coping skills training is more effective than arthritis education in decreasing knee pain during functional activities, and (2) Pain coping skills training is more effective than usual care in decreasing knee pain during functional activities. We also will examine two sets of secondary hypotheses: (1) Pain coping skills training is more effective than arthritis education or usual care in improving self-reported function, physical performance, pain intensity, pain catastrophizing, and patient global ratings of improvement and (2) Pain coping skills training will reduce direct medical costs and indirect (i.e. patient time) costs relative to arthritis education and usual care. We hypothesize that, in addition to accounting for costs associated with pain coping skills training, the intervention will be cost saving or cost-effective relative to arthritis care education and usual care as measured by the incremental cost per quality-adjusted life-year. We will also determine if treatment benefits are mediated by changes in pain catastrophizing: We hypothesize that treatment-related changes in pain catastrophizing will mediate treatment-related improvements in pain and self-reported function during recovery.The KASTPain Trial is a three-arm randomized trial  Virginia Commonwealth University in Richmond, Virginia; (2) Southern Illinois University in Springfield, Illinois; (3) Duke University in Durham, North Carolina; and (4) Wake Forest University, Winston-Salem North Carolina. To be eligible for participation all patients must: (1) be able to read and speak English and provide informed consent; (2) be 45 years or older; (3) have a diagnosis of osteoarthritis as determined by the patients’ orthopaedic surgeons; (4) be scheduled for an elective unilateral total knee arthroplasty no sooner than 2 weeks or later than 8 weeks from the time of recruitment; and (5) score of ≥ 16 on the Pain Catastrophizing Scale and ≥ 5 on the WOMAC Pain scale. Scores of 16 or greater on the Pain Catastrophizing Scale suggest at least a moderately severe pain catastrophizing while scores of ≥ 5 on the WOMAC Pain Scale suggests greater than minor function limiting pain. Patients will be excluded if they: (1) are scheduled for revision arthroplasty surgery; (2) are unable to or decline consent for study participation; (3) have a self-reported diagnosis of inflammatory arthritis ; (4) have TKA scheduled because of a fracture, malignancy or an infection; (5) are scheduled for bilateral TKA; (6) are scheduled for unicompartmental arthroplasty; (7) report plans to undergo hip or knee arthroplasty within one year after current TKA; (8) underwent contralateral knee arthroplasty surgery or hip arthroplasty surgery within 1 year of currently planned surgery; or (9) score 20 or higher on the Patient Health Questionnaire-8 (PHQ-8) depression screener which indicates likely severe depression,37. PregAll patients scheduled for TKA with orthopaedic surgeons who conduct at least 50 TKAs per year at one of the four university-based study sites will potentially be eligible for study. We will only recruit surgeons who conduct ≥ 50 TKAs per year because of the potential influence of TKA volume on outcome. FollowiTwo in-person data collection sessions will occur for each patient, one at the baseline visit and the other at 1 year following TKA. In addition, staff that are blinded to group assignment will contact patients by phone at 4 different time points; 1 week prior to and 1 week following TKA, 2 months, 6 months following TKA  will be delivered over a 2-month period by physical therapists. This number of sessions of CST has been shown to be effective in several behavioral trials-50. StudThe (CST) protocol will: (1) provide a rationale for the coping skills intervention; (2) train patients in cognitive restructuring as well as a variety of skills that provide patients with opportunities to observe the impact of coping skills on changes in negative pain-related cognitions typical of pain catastrophizing ; and (3) provide training in strategies for enhancing maintenance of gain following treatment. Melzack and Wall's gate control model of pain will be used to help patients reconceptualize their pain and emphasize their own abilities to control pain. The gate control model highlights the role that thoughts, feelings, and behaviors can play in influencing the transmission of noxious signals from the periphery to the brain. TraininUsing techniques drawn from cognitive therapy, patients will be taught how to identify irrational, maladaptive, and catastrophic pain-related thoughts and to replace these with alternative, rational, reassuring and adaptive thoughts. Self-inPatients also will be trained in three attention diversion methods that can be used to alter negative pain related cognitions: relaxation, imagery, and distraction. Progressive relaxation training will helPatients randomly assigned to the arthritis education arm will receive detailed information from a registered or licensed practical nurse educator about osteoarthritis and its treatment. The arthritis education intervention will control for participation in a trial, time and clinician attention. The arthritis education sessions will use a presentation and discussion format similar to that originally described by Lorig for arthritis education-62. FiguThis general approach to an arthritis education comparison condition has been used successfully in many behavioral studies and in several trials conducted by Keefe and Jensen-50,62. AWe have added a “usual care” group to determine real world effects of pain coping skills. Patients in the usual care group will only receive care that they would have routinely received had they not been entered in the study. All patients in this group will undergo the same data collection procedures as patients in the other two treatment arms with the exception of the eight treatment sessions.Patients are routinely prescribed medications for pain control and are referred for physical therapy following TKA. Data regarding medication and extent of rehabilitation therapies will be tracked throughout the study period and will be adjusted for, if necessary, in the analyses.Because multiple study sites will participate and increase the risk of low fidelity due to differing approaches in applying the interventions, the research team will take a number of steps to ensure that the treatment protocols for CST as well as arthritis education are delivered uniformly by all treatment providers involved in the study. First, all pain coping skills training will be delivered by physical therapists with at least 2 years of clinical experience including the treatment of patients following TKA. Second, all physical therapists will receive coping skills training in a 2-day workshop delivered by clinical psychologist experts at Duke University. Experienced nurse educators will all be trained in 2-day workshops by DLR, a physical therapist with 30 years of experience and research in arthritis and rehabilitation, to provide the arthritis education. Third, all physical therapists and nurse educators will be provided with detailed treatment manuals and the treatment strategies will be taught through didactic instruction, illustrations of techniques from model cases, and role-play of common scenarios. Fourth, we will institute several “best practices” to enhance and monitor treatment fidelity of the pain coping skills training and arthritis education which include: (1) careful attention to the study design; (2) intensive training; (3) role playing of treatment skills enactment during training; and (4) on-line documentation of treatment delivery. All sessions for both groups will be audiotaped and supervisors or investigators will review tapes periodically for each physical therapist and nurse educator during the study. Remedial training will be provided for those clinicians who deviate from established protocol.The primary outcome measure and endpoint will be the WOMAC Pain score measured 1 year following knee arthroplasty-67. The The primary endpoint will be the WOMAC Pain score at 1 year. Changes of 2 or more points in the 20-point WOMAC Pain scale indicate clinically important differences in pain-related function between individual patients-81. We pUsing a two-sided, two-group t-test of differences in means with alpha set at 0.05 and assuming the intervention difference minus the arthritis education control difference is at least 2 WOMAC Pain points, a sample size of 107 in each group will provide 91% power to detect this difference, assuming that the common standard deviation is 4.34 (based on pilot work). This corresponds to a moderate effect size of 0.46 which is consistent with the effect of other behavioral interventions for knee arthritis-85. ThisThe required sample size is 321 (107 patients per arm) for the planned three-arm trial. Based on our pilot study, we expect 5% attrition due to early drop-out resulting from cancelled surgery. Patients who undergo surgery and drop out due to lack of interest, unrelated medical illness or loss of follow-up will be included in the intent-to-treat analysis. Our previous work with similar types of patients suggests that loss to follow-up will likely be approximately 20% one year following surgery,30. TherIntention to treat (ITT) will be the primary approach for all analyses. Because we expect that some patients will provide consent for our study but may opt out of surgery for a variety of reasons, we will compare the ITT analysis to the results for patients who actually undergo surgery . For the primary analysis, the effect of treatment will be assessed using linear mixed models with time as a repeated factor. The model will account for correlation over time within participants, correlations within surgeons, and baseline covariates. Surgical approach, complications, medication and physical therapy use will be assessed for potential effects. Restricted maximum likelihood method (REML), which uses all available data, will be used to estimate the linear mixed model. REML is the default option in multiple software packages for mixed models including SAS and Mplus. Wothke has shown that no other missing data handling method, regardless of missing data mechanism, performs better.Estimates of the effect of pain coping skills training will be obtained by constructing linear contrasts to compare the outcome at each of the key time points  between the pain coping skills group and the two control groups, with adjustment for the other variables. Analyses of the secondary outcome variables will be conducted using a similar approach. For the analyses using dichotomous outcomes of ≥50% improvement at 6 months and 12 months, generalized linear models with logistic regression will be used to compare the proportion of patients with ≥50% improvement after adjustment for covariates.As an additional secondary analysis, we also will examine the effects of potential moderators. Moderators are patient characteristics that predict treatment effects. AdditioWe will also compare medical resource use and mean total costs incurred over the one-year follow-up period in the KASTPain study between patients randomized to coping skills training vs. arthritis education vs. usual care. Counts of medical resource use will include inpatient stays, outpatient visits to physicians, physical therapists and other providers, and days of pain medication. Sources for unit costs assigned to medical resource use will include average Medicare payments for inpatient care and outpatient services and average wholesale prices published in the Red Book for medications. The TEAM-HF Costing Tool will be used to estimate intervention costs by accounting for providers’ time spent delivering the study intervention. Total cA cost-effectiveness analysis will also be performed. Incremental cost-effectiveness ratios (ICER) will be calculated as the difference in the mean costs per patient between study arms divided by the difference in estimated quality-adjusted life-years (QALYS). Mean costs will be estimated as described above. QALYs will be estimated using patient-level utility estimates derived from the EQ-5D, administered at baseline, 2 months, 6 months and 1 year. BecauseOur study will be the first to examine the efficacy of a pain coping skills training intervention delivered by physical therapists to patients at risk for poor outcome following orthopaedic surgery. The use of physical therapists as interventionists is innovative because the intervention is traditionally delivered by clinical psychologists. However, given the limited availability of clinical psychologists and the large volume of TKA procedures, physical therapists routinely treat patients prior to and following TKA and are optimally positioned to provide coping skills training.Previous work by our group and otheTKA: Total knee arthroplasty; WOMAC: Western Ontario and McMaster Universities Osteoarthritis Index.; NIH: National Institutes of Health; PHQ-8: Patient Health Questionnaire-8; CST: Pain coping skills training; PCS: Pain Catastrophizing Scale; NNT: Number needed to treat; ITT: Intention to treat; REML: Restricted maximum likelihood method; ICER: Incremental cost effectiveness ratio; QALYS: Quality adjusted life years.Drs. Riddle, Keefe Ang, Saleh, Dumenci, Jensen, Bair, Reed and Kroenke have no competing interests to declare.All authors participated in the conception and design of the protocol and helped to draft the manuscript. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2474/13/149/prepub


Aims: The aim of this study was to investigate psychological distress, anger and alexithymia in a group of patients affected by myofascial pain (MP) in the facial region.Methods: 45 MP patients [mean (SD) age: 38.9 (11.6)] and 45 female healthy controls [mean (SD) age: 37.8 (13.7)] were assessed medically and psychologically. The medically evaluation consisted of muscle palpation of the pericranial and cervical muscles. The psychological evaluation included the assessment of depression (Beck Depression Inventory—short form), anxiety [State-Trait Anxiety Inventory Form Y (STAI-Y)], emotional distress [Distress Thermometer (DT)], anger [State-Trait Anger Expression Inventory—2 (STAXI-2)], and alexithymia [Toronto Alexithymia Scale (TAS)].Results: the MP patients showed significantly higher scores in the depression, anxiety and emotional distress inventories. With regard to anger, only the Anger Expression-In scale showed a significant difference between the groups, with higher scores for the MP patients. In addition, the MP patients showed significantly higher alexithymic scores, in particular in the Difficulty in identifying feelings (F1) subscale of the TAS-20. Alexithymia was positively correlated with the Anger Expression-In scale. Both anger and alexithymia showed significant positive correlations with anxiety scores, but only anger was positively correlated with depression.Conclusion: A higher prevalence of depressive and anxiety symptoms associated with a higher prevalence of alexithymia and expression-in modality to cope with anger was found in the MP patients. Because the presence of such psychological aspects could contribute to generate or exacerbate the suffering of these patients, our results highlight the need to include accurate investigation of psychological aspects in MP patients in normal clinical practice in order to allow clinicians to carry out more efficacious management and treatment strategies. Temporomandibular disorders (TMDs) are a heterogeneous group of disorders associated with dysfunctions of the muscles of mastication, temporomandibular joints (TMJ) and related structures. One of commonest types of TMDs are myofascial pain syndromes (MPS). MPS are characterized by a particular kind of non-articular musculoskeletal pain, associated with discrete taut bands of hardened muscle that contain regions of exquisite muscle dysfunction and tenderness  is still unclear. Recent studies evidence a multifactorial etiology: genetic, physical, and psychological/psychiatric factors, as well as life-span psychosocial stressors seem to be involved in the onset and evolution of MPS  age of 38.9 (11.6) and a mean (SD) of educational level of 13 (3.1) years . Because the majority of patients who seek treatment for MP are women  was composed by a sample of 45 voluntary healthy women, balanced for age [37.8 (13.7) years] and educational level [14.4 (4) years]. The exclusion criteria were: low educational level (<5 years' schooling), the inability to fill out the questionnaires due to an insufficient knowledge of Italian and the presence of organic pathologies, including TMJ disorders, chronic pain, or psychiatric disorders (Axis I and II of the DSM-IV-TR). Written informed consent was obtained from all participants.Before the medical examination, all the patients and healthy controls filled in a data sheet assessing their medical and psychiatric case history. Medical history included a record of pain characteristics, improvement, or aggravating factors and associated symptoms. All the patients and control subjects were assessed by the same dentist (D.I.).The psychological scales and inventories were delivered and scored by the same expert psychologist (D.F.), after excluding major mood or anxiety disorders (according to the criteria of the DSM-IV-TR).2 of force) of the pericranial and cervical muscles and was carried out by an expert clinician. The muscles examined were: (1) masseter, (2) lateral pterygoid, (3) medial pterygoid, temporal (4) mandibular, and (5) cranial insertion ; sternocleidomastoid (1) belly and (2) cranial insertion, (3) trapetius, (4) nucal muscles   ranging from 0 (No pain) to 10 (Extreme pain).The psychological evaluation included the assessment of psychological distress symptoms , anger, and alexithymia.Psychological distress—depressive, anxiety, and emotional distress symptoms—was evaluated by means of the following self-report scales.The BDI-SF is a self–report measure composed of 13 items, rated on a 4-point scale ranging from 0 to 3, that assess the presence of depressive symptoms  differentiates between temporary or emotional state anxiety and long standing personality trait anxiety in adults  is a simple checklist assessment tool commonly used in cancer care and other areas of physical health, such as chronic pain  is a self-report scale composed of 57-items on a 4-point scale. It measures the intensity of anger experienced at a particular moment and the frequency with which the subject experiences, expresses, and controls feelings of anger  is a self-report scale consisting of 20 items rated on a 5-point Likert scale , the Difficulty Describing Feeling subscale (F2), and the Externally-Oriented Thinking subscale (F3). The Italian version of the TAS-20 has demonstrated factorial validity, a good internal consistency , and a high test-retest reliability over two-weeks   showed a significant positive correlation with both depression score (BDI) and state and trait anxiety scores (STAI- Y1 and Y2), whereas no significant correlation was found with the emotional distress level (DT). In addition, Anger Expression-In scores showed a significant positive correlation with alexithymia .Correlation analysis was run only with variables showing a significant difference between the MP and the C group. These analyses are detailed in Table The TAS-20 total score and the F1 factor were significantly positively correlated with state and trait anxiety scores (STAI- Y1 and Y2). No significant correlations were found between alexithymia and the emotional distress, and between alexithymia and depression (the correlations did not reach the significant level after applying the Bonferroni correction).The correlation between the clinical indexes and psychological scales are shown in Table The aim of this study was to compare psychological distress, anger and alexithymia between a group of myofascial facial pain patients and a control group composed of healthy women, in order to identify the characteristic components of the MP patients. The relationships between psychological and clinical aspects were also analyzed.The psychopathological characteristics associated with chronic pain pathologies have been widely investigated, but few studies have focused on MPS and most of them focused only on depression and anxiety.Although the close relationship between chronic pain and depression is well documented (Torta and Munari, While the presence of depression in MPS is already well known, the role of anxiety is still under debate. Its role has been investigated in only a few studies, most of which analysed the presence of anxiety in TMDs, with contrasting results (Kino et al., Another commonplace feature in chronic pain patients is anger. Studying the presence, intensity, expression modalities and targets of anger may be important for understanding psychological adaptation to chronic pain (Okifuji et al., Alexithymia is commonly present in people with psychosomatic or psychiatric disorders and is highly prevalent in chronic non-malignant pain patients (Lumley et al., It has been speculated that the characteristics of alexithymic individuals seem to reflect the type D personality profile, which is characterized by high tendency to experience negative emotions and to inhibit the expression of emotions/behaviors in social interactions (Ogrodniczuk et al., In contrast with previous study, we did not find any correlation between the clinical and the psychological parameters, possible due to methodological issues. In particular, the PTS and the CTS index have a very restricted range that could strongly influence the correlation's results. Mongini et al.  found thIn conclusion, our results showed a high presence of psychopathology in the MP patients. Going further than previous studies, as well as confirming the high prevalence of depressive symptoms, our results suggest that MP patients are significantly more anxious, have a higher prevalence of alexithymia and an higher expression-in modality to cope with anger than healthy matched controls. Taken as a whole, the results of our case-control study highlight the need to include an accurate and specific psychological assessment of patients with MP in order to identify those psychological aspects, such as alexithymia and emotion management style, that could contribute to generate or exacerbate the suffering of these patients. It has, in fact, been suggested that the inability of individuals with alexithymia to adequately identify physical sensations, such as the somatic manifestations of emotions, makes it likely that they will incorrectly attribute innocent physical symptoms to physical disease (Tuzer et al., The main limitations of this study are the relatively small number of patients and the fact that the patients were enrolled from a single center. Further multicenter studies including a higher number of patients should be carried out in order to confirm these results and better understand the relationship between psychological symptoms and pain in MP patients.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


To evaluate the impact on clinical outcomes by providing acupuncture as an option for acute pain management in the emergency department (ED) of a major metropolitan hospital in Melbourne, Australia.Adult patients (aged 18+ years) with acute pain attending the ED were initially assessed by medical staff and/or acupuncture staff for the suitability of acupuncture treatment. A total of 200 patients received acupuncture treatment. The selection of points for treatment was based on Chinese medicine diagnosis and theory. The treatment duration was 30 minutes on average with or without electrical stimulation. A Visual Analogue Scale (VAS) to measure pain scores before and after acupuncture treatment was the primary outcome.Pain in the abdominal or flank region and muscle and musculoskeletal related pain were the common conditions treated (83%). A significant difference in the scores of before (mean = 7.01) and post treatment (mean = 4.72) was observed . Four patients (2%) reported adverse events during the course of the acupuncture treatment. These included two cases of slight bleeding with the other two cases of mild pain at the needling sites. No serious adverse events were reported. More than half (52.5%) of patients indicated that they would definitely consider acupuncture in the future for the same health condition and a further 31.8% said they probably would consider acupuncture again.Acupuncture can be an effective and safe adjunct intervention for patients with acute pain in settings such as the emergency pain management environment.


Allergenic tropomyosins are highly cross-reactive panallergens found in various invertebrates. Sensitized patients can develop allergic responses ranging from oral allergy syndrome to severe anaphylactic reactions after the ingestion of tropomyosin-containing food. The usual routs of sensitization to tropomyosin include the airborne exposure to various mites and cockroaches and the oral intake of crustaceans and mollusks. There were also reports of patients with combined mite and seafood allergy who had experienced a worsening of food allergy symptoms during house dust mite-specific immunotherapy (HDM-SCIT). Therefore, a possibility that mite tropomyosin present in allergen extracts can cross-sensitize patients receiving HDM-SCIT and thus induce food allergy is still investigated.Our aim was to assess the occurrence and the clinical relevance of tropomyosin sensitizations in HDM-SCIT-treated patients.We studied 56 HDM-allergic patients treated with mite extract-SCIT. All of them were initially screened for sIgE to mite tropomyosin (rDer p 10) before and after SCIT. In those with a positive result we also monitored the dynamics of sIgE to both mite and shrimp (rPen a 1) tropomyosins at five time points: prior to treatment, after initial therapy (~4 months), 1 and 2 years after starting therapy, and after its completion. The levels of sIgE were measured by the CAP-System FEIA.sIgE to tropomyosin was found in only 5 patients. Of those, 3 expressed low and clinically irrelevant levels of sIgE to Der p 10 during SCIT, while sIgE to Pen a 1 was not found at all. The remaining 2 patients expressed sIgE to both tropomyosins. In the first, initial increase and subsequent decrease resembled the dynamics of IgE-antibodies usually seen in SCIT patients, while clinically he had never expressed an allergic reaction to tropomyosin-containing foods. In the other, who used to develop oral allergy syndrome after consuming squids or shrimps before SCIT, a decrease of sIgE to both tropomyosins resulted in the complete loss of his reactivity toward seafood.Induction of clinically relevant tropomyosin sensitizations is an unlikely consequence of HDM-SCIT.In some cases of combined mite and seafood allergy the treatment may even lead to the improvement of food allergy symptoms.The levels of sIgE to tropomyosins might be useful in monitoring, especially if their cutoff values predictive of the reaction severity could be determined.None declared.


Perioperative intravenous (IV) infusion of lidocaine has been shown to decrease post-operative pain, shorten time to return of bowel function, and reduce the length of hospital stay. This randomized, prospective, double-blinded, placebo-controlled clinical trial evaluated the impact of IV lidocaine on the quality of post-operative analgesia and other outcomes after hand-assisted laparoscopic colon surgery.t test. All statistical tests were two-tailed at a significance level of 0.05.Sixty four patients with colon cancer scheduled for elective colon resection were involved in this study. Patients were randomized to receive either lidocaine infusion [lidocaine group (LG)] or normal 0.9 % saline infusion [placebo group (PG)] for a period of 24 h. Anaesthetic and surgical techniques were standardized. Twenty-four-hour post-operative analgesia in the recovery area was maintained by continuous infusion of 0.1 μg/kg/h fentanyl. The primary outcome of the study was post-operative pain control. Pain was assessed using visual analogue scale (VAS) scores at 2, 4, 8, 12, and 24 h after surgery. Patients with a VAS score >3 were treated with ketorolac 30 mg as needed. Secondary outcomes included time to resumption of bowel function and length of hospital stay. Data in the two groups were compared using the two-tailed Student’s p = 0.047). Compared with placebo, lidocaine infusion produced a 32 % reduction in time to the first drink (Cohen’s d = 3.85), 16 % reduction in time to the first full diet (Cohen’s d = 3.35), and 18 % reduction in time to the first bowel movement (Cohen’s d = 2.30). Patients who received lidocaine stayed in hospital 1.2 days less than patients who received placebo . There were no significant differences in surgery-related complications between the two groups.Demographic characteristics and clinical features of both groups were similar. Intensity of pain at rest in LG compared with PG was significantly lower during the first 24 h post-operatively. LG patients reported significantly less pain during movements at 2-, 12-, and 24-h post-surgery than PG patients. The study showed that ketorolac consumption was significantly higher in PG: mean ketorolac consumption in LG was 43.77 ± 13.86 mg and in PG 51.67 ± 13.16 mg (Perioperative continuous IV lidocaine infusion has a beneficial effect as regards post-operative pain, restoration of bowel function, and length of hospital stay in patients who have undergone hand-assisted laparoscopic colon surgery. Clinical and scientific data show that laparoscopic methods in colon surgery accelerate dietary intake and return of bowel function, facilitate post-operative mobilization, reduce the length of stay in hospital, and reduce the post-operative mortality rate –6. A numFurthermore, post-operative pain management in the treatment of acute pain after HALS  improves both the success of the surgical intervention and patient comfort –7. To daRecently, there has been a surge of interest in the use of IV lidocaine in abdominal surgery due to its analgesic, antihyperalgesic, and anti-inflammatory effects. It has been shown that perioperative administration of IV lidocaine decreases post-operative pain, minimizes the use of opioids, facilitates earlier restoration of bowel function, and shortens the length of hospital stay after colon surgery , 10.The aim of this study was to assess the effectiveness of IV lidocaine versus placebo on the post-operative pain level, requirements for analgesics, duration of post-operative ileus, and length of hospital stay in patients undergoing hand-assisted laparoscopic colon surgery.This randomized prospective double-blinded placebo-controlled single-centre trial was performed at the Institute of Oncology, Vilnius University, Lithuania. The study was approved by the Local Ethics Committee and written informed consent was obtained from all patients.Consecutive adult patients 18–75 years old with colon cancer scheduled for an elective laparoscopic colon resection under general anaesthesia were invited to participate in this study. Patients were enroled from March 2010 until March 2012. Patients American Society of Anaesthesiologists (ASA) score of I, III, or III, with normal cognitive function and able to give informed consent, were eligible for inclusion in the study. Patients with severe hepatic, renal, cardiac, respiratory, and endocrine disease and history of alcohol or drug addiction, those taking analgesics pre-operatively and those with allergy to local anaesthetic were excluded from the study.The study hypothesis was that lidocaine infusion would result in better pain relief, earlier resumption of bowel function, and a shorter hospital stay in patients undergoing hand-assisted laparoscopic colon surgery.For all patients, anaesthetic management was standardized and based on the standards of care adopted in our institution. General anaesthesia was provided to all patients using fentanyl 1.5 μg/kg and propofol 2 mg/kg for induction, and tracheal intubation was achieved with rocuronium. Intraoperative muscle relaxation was monitored using a nerve stimulator. Arterial blood pressure and heart rate were maintained within 20 % of baseline values. Supplemental doses of 50 μg of fentanyl were administered if intraoperative blood pressure or heart rate were 20 % higher than baseline. Intraoperative blood pressure or heart rate 20 % lower than baseline was treated with IV ephedrine. Anaesthesia was maintained with sevoflurane in a mixture of air 40 % and oxygen 60 %, and end-tidal concentration of sevoflurane was adjusted to maintain the bispectral index within range, between 40 and 60. Twenty-four-hour post-operative analgesia in the recovery area was maintained by continuous infusion of 0.1 μg/kg/h fentanyl.For LG patients, an IV bolus of lidocaine 1.5 mg/kg was given (maximum 100 mg) just before the induction of anaesthesia, followed by an IV infusion of lidocaine 2 mg/kg/h during the entire surgical procedure. The dose of lidocaine was then lowered to 1 mg/kg/h in the post-operative anaesthesia care unit and continued for the first 24 h after surgery. PG patients received the same amount of pre-operative bolus and continuous infusion of normal saline during surgery and for 24 h after the operation.All hand-assisted laparoscopic colon operations were carried out by the same team of surgeons experienced in this procedure. With the patient under general anaesthesia, in a supine horizontal position with legs stretched, body fixed to the operating table and operator standing between the stretched legs, a 6–6.5 cm transumbilical incision is performed. The assistant is standing on the right side of the patient and the scrub nurse on the left side. The laparoscopic port is inserted and a left hand is introduced into the abdomen. Under hand control, a 5-mm trocar is inserted in the left lateral quadrant few centimetres above and towards the midline from the anterior superior iliac spine, and a 10-mm trocar is inserted at the level of the right midcalvicular line few centimetres above the umbilicus . A 12-mm trocar is inserted 2–3 cm towards the midline and 2–3 cm below the right anterior superior iliac spine. Mobilization begins with the descending colon moving upwards to splenic flexure and left side of transverse colon, using a hand and a harmonic scalpel . After this part is finalized, the operator moves to the right side of the patient (same as assistant surgeon) and mobilization continues with the sigmoid colon, then lifting the rectosigmoid colon at the level of the promontorium with superior rectal vessels and continuing the mobilization from the left side, using a 12-mm trocar for the harmonic scalpel, visualizing the left ureter . Then, the inferior mesenteric artery is mobilized and ligated using titanium 10-mm clips 1–2 cm from the aorta, and the inferior mesenteric vein is mobilized and ligated with same clips at the level of the ligament of Treitz. The specimen is divided at the level of the promontorium, using an endoscopic linear stapler (60 mm). The specimen is removed through the hand port incision, and further anastomosis is fashioned laparoscopically using a double-stapling technique. The water–air leak test is performed and the doughnuts are examined to ensure completeness. No drain is routinely used. The fascia is closed at the level of the 12-mm trocar with a single interrupted suture, and the hand port with a running polydioxanone 0 suture. The skin incisions are closed with interrupted sutures.Patients were allocated to LG or PG before surgery using a computer-generated randomization list of random numbers. An anaesthesia nurse not involved in the patients’ treatment and evaluation drew lidocaine or normal saline into two syringes labelled with each patient’s number and the administration route: for bolus and for infusion. Patients and those who gathered data  were blinded to study allocation.The primary outcomes of the study were post-operative pain control evaluated by determining the intensity of pain and ketorolac consumption. The intensity of abdominal pain at rest and during movement  was assessed regularly at 2, 4, 8, 12, and 24 h after the operation using visual analogue scale (VAS) pain scores . Patients received an information sheet and verbal training on completing the pain scores. Patients with a VAS score >3 were treated with IV ketorolac 30 mg as needed. Ketorolac consumption was registered.Secondary outcomes included time to resumption of bowel function and length of hospital stay. All patients were instructed to report the time of the first flatus and bowel movement. The patient informed the nursing staff, who documented the time. Patients were discharged from the hospital after pain control using oral pain medication had been optimized, bowel function had resumed, and they had started to tolerate a solid diet, had become mobile, and were able to perform daily activities independently or with minimal aid. There were no changes in trial outcomes after the start of the study.Data collected as well included surgery-related complications .α = 0.05 and power of 80 %, it was calculated that a minimum of 24 patients/group was required. One of the secondary outcomes was time to the first bowel movement. The average time to return of bowel movements in the lidocaine subgroup of the study of Groudine et al.  are presented as mean ± SD and 95 % confidence interval (CI) and analyzed using Student’s All statistical tests were two-tailed at a significance level of 0.05. Statistical analysis of data was performed using SPSS version 18 for Windows .2.Sixty-four consecutive adult patients  with a diagnosis of colon cancer were recruited for the study. All patients underwent hand-assisted laparoscopic hemicolectomy. Thirty-two patients were randomized to receive lidocaine and 32 patients to receive normal saline as placebo. Four patients had to be excluded from final analysis because HALS was converted to laparotomy. The data of 60 patients were analyzed   Fig. . Differep < 0.01)  Fig. . Differep = 0.181). Patients receiving lidocaine consumed significantly less ketorolac: mean ketorolac consumed by patients receiving lidocaine was 43.77 ± 13.86 mg and PG patients received on average 51.67 ± 13.16 mg of ketorolac .Twenty-seven (90.0 %) of PG patients required ketorolac and 22 (73.3 %) of LG patients required ketorolac (p < 0.01). Differences in time remained significant after adjusting for ketorolac usage. Compared with placebo, lidocaine infusion produced a 32 % reduction in time to the first drink (Cohen’s d = 3.85), 16 % reduction in time to the first full diet (Cohen’s d = 3.35), and 18 % reduction in time to the first bowel movement (Cohen’s d = 2.30).Clinical data from the post-operative period are presented in Table p < 0.01, Cohen’s d = 0.72).Patients who received lidocaine stayed in hospital 1.2 days less than patients who received placebo  between the groups Table .Table 3IDespite a slow start, there has recently been a substantial increase in the number of units performing laparoscopic colorectal surgery for benign and malignant disease , 15. LapA standard method of post-operative analgesia for patients undergoing laparoscopic colorectal surgery has not yet been developed, and this has led to the employment of various types of analgesia. These have included epidural, intrathecal analgesia, patient-controlled analgesia, and IV agents.More recently, Kaba et al.  reportedThe analgesic and anti-inflammatory effects of systemic lidocaine administration may be a result of block or inhibition of nerve conduction . This isLidocaine toxicity follows a predictable progression and can be divided into central nervous system and cardiovascular effects. At low plasma concentrations, these include numbness of the tongue and perioral tissues. If plasma concentrations reach higher levels, restlessness, vertigo, tinnitus, and accommodation disorder may be apparent. Other adverse reactions caused by high concentrations may involve slurred speech, skeletal muscle twitching, and drowsiness followed by seizures. Although the side effects are dose-dependent, they are more frequent at higher infusion rates (more than 3 mg/min). In this study, lidocaine was infused at 1 mg/min for 24 h, and there were no adverse reactions. Lidocaine toxicity tends to occur at high plasma concentrations (more than 5 mkg/mL) and has not been seen even when infused during longer periods .In previous studies , 27, 28,The results of this study indicate that perioperative use of IV lidocaine significantly reduces pain after surgery compared with placebo in laparoscopic colorectal surgery.Previous studies of visceral surgery , 27, 28 Therefore, we suggest that the impact of perioperative low-dose lidocaine infusion on length of hospital stay was of a true benefit, consistent with previous results , 10, 13.LG patients proved to have quicker recovery of bowel function as evidenced by earlier time of first flatus as well as first bowel movement. In our study, LG patients had a bowel movement more than 24 h earlier than PG patients and were discharged 1.2 days earlier.The findings of Wongyingsinn et al.  and SwenPost-operative nausea and vomiting are substantial problems, since even mild nausea and vomiting can delay discharge from hospital, leading to increased costs and decreased patient satisfaction . The preIt remains unclear why patients undergoing abdominal surgery may particularly benefit from IV lidocaine infusion. One explanation might be the differences in pain mechanisms; visceral pain from abdominal surgery might be triggered by mechanisms other than those involved in non-visceral pain. Part of the discomfort and pain following abdominal surgery might be related to post-operative ileus and nausea/vomiting. Indeed, the reduction observed in the time to bowel function recovery as well as the decreased incidence of nausea/vomiting might explain why the improvement in pain control was observed mainly in studies based on abdominal surgery.There are some limitations associated with this study. The present study analyzed pain scores and ketorolac usage during the first 24 h after surgery at the same time patients were receiving continuous infusion of 0.1 μg/kg/h fentanyl. No data were collected on pain scores and analgesic usage on the further days until discharge. Ketorolac usage by patients in terms of pain scores and time was not analyzed. Although our study showed advantages of IV lidocaine in post-operative pain relief, we failed to show its superiority compared with epidural anaesthesia. Also, our study did not provide any data concerning cost-effectiveness. To clarify both items, further studies are needed. Finally, out prospective randomized trial was not registered with ClinicalTrials.gov.Continuous IV lidocaine infusion has a beneficial effect in patients who have undergone HALS and decreases post-operative pain, facilitating early restoration of bowel function and shortening length of hospital stay.


Due to the increase of life expectancy, the prevalence of degenerative spine diseases such as adult degenerative lumbar scoliosis (ADLS) has been increasingly more than before which is required appropriate control and management. Therefore, the present study was aimed to survey the result of surgery in ADLS patients in Shiraz (Iran).This is a preliminary report of 30 patients with ADLS who underwent pedicular screw fixation, posterolateral fusion, posterior decompression and correction of coronal plane deformity operation according to surgical indications in the Chamran and Kowsar hospitals during 2009-2011. The patients were followed up at 1, 6 and 12 months post operation. Radiologic changes were evaluated and the Oswestry low back pain disability (OLBP) scale and visual analogue scale (VAS) were used to evaluate functional and pain improvement, respectively. Data were analyzed using SPSS software version 15. We used Wilcoxon signed-rank test to compare the parameters of pain and LBP scale.Primary analysis showed that 42.9% of operated patients were in 50-60 years age group. 71% of the patients were female and 29% were male. Prevalence of LBP from radicular pain among the patients was 95.2%. There was a significant difference between pre-operation and post-operation VAS and Oswestry LBP scale (P less than 0.001).Our findings showed that posterior decompression combined with pedicular fixation, posterolateral fusion and correction of coronal plane deformity seems to be a suitable method for the relief of pain and improvement of function in ADLS patients. Only decompression can relieve low back pain but for the relief of radicular pain and correction of deformity, fixation and fusion are recommended.Scoliosis, Degenerative, Low back pain, Adult lumbar, Radicular pain