P = .018) and the number of veins ligated , were significantly associated with changes in NRS after surgery. In addition, the area under the receiver operating characteristic curve for changes in NRS and the total number of veins ligated was 0.869. Microsurgical varicocelectomy had a high success rate for scrotal pain and satisfaction. Severe varicocele grade and the number of veins ligated in microsurgical varicocelectomy were associated with postoperative pain improvement.Varicocele is a major cause of male infertility. However, few studies have discussed the potential associations between the pain caused by varicocele and preoperative and intraoperative factors. The aim of this study was to evaluate factors potentially associated with changes in pain score after microsurgical varicocelectomy. This retrospective study was conducted between August 2020 and August 2022 at China Medical University Hospital in Taichung, Taiwan. Patient characteristics including age, body mass index, semen analysis, testicular volume, and the number of veins ligated were collected. Preoperative and intraoperative factors were analyzed to determine if they were correlated with changes in numeric rating scale (NRS) after microsurgical varicocelectomy. A total of 44 patients with clinical varicocele underwent subinguinal microsurgical varicocelectomy and were analyzed. The overall pain resolution rate was 91%, and the average satisfaction score after surgery was 9.2 according to their subjective feelings. Multivariate analysis revealed that severe varicocele grade (odds ratio [OR] 16.5, 95% confidence interval [CI] 3.01–90.47;  Most research on varicocele has focused on the link between varicocele and infertility, however, a significant number of patients come to our clinic seeking help because of varicocele-related discomfort. The pain caused by varicocele is characterized as a dull, throbbing, or aching sensation in the groin, scrotum, or testicle. Scrotal heaviness that intensifies with exercise or extended periods of standing can also be described as a varicocele.Varicocele is an enlarged and tortuous pampiniform venous plexus in the spermatic cord which commonly causes scrotal pain.,3The etiology of scrotal pain associated with varicocele is not fully understood. Previous studies have mentioned possible mechanisms, such as compression of adjacent neural fibers by a dilated venous complex, increased scrotal temperature, oxidative stress to the testicular parenchyma, and tissue ischemia resulting from venous stasis.,5 Varicocelectomy is indicated when conservative treatments fail. However, according to prior literature, up to 20% of individuals who undergo varicocelectomy may experience only partial or no improvement after surgery. Many studies conducted over the past 20 years have documented the advantages of varicocelectomy for uncomfortable varicoceles.–8 Several studies have investigated whether clinical characteristics can predict surgical outcomes, with controversial findings. Some studies have reported that varicocele grade, pain quality and severity can predict favorable results,–9 whereas others have found no correlation.,11 Therefore, the aim of this study was to assess the efficacy of microsurgical varicocelectomy for treating scrotal pain and reevaluate the factors potentially related to changes in the patient pain score after microsurgical varicocelectomy.Conservative treatments, including anti-inflammatory drugs, scrotal support, and decreased physical activity are usually first-line therapies for varicocele-related discomfort. Multivariate analysis was performed on the preoperative and intraoperative factors potentially associated with changes in the numeric rating scale (NRS) score and collected as our primary outcome.This retrospective study was conducted between August 2020 and August 2022 at China Medical University Hospital in Taichung, Taiwan, during which 90 patients came to our clinic due to chronic scrotal pain. We excluded patients with other etiologies of scrotal pain, including orchitis, epididymitis, chronic pelvic pain syndrome, hydrocele, inguinal hernia, benign testicular mass, and recurrent varicocele after varicocelectomy. The remaining 44 patients received microsurgical subinguinal varicocelectomy and were enrolled in this study Fig. . The patThe presence of pain was recorded subjectively the first time the patient visited our out-patient clinic and at the post-operative follow-up (post-operative day 7). The pain level was rated using an NRS from 0 (painless) to 10 (the most pain ever experienced). Pain resolution was defined as remission of symptoms such as pain or no further treatment required 3 months after the operation, while pain resolution failure was defined as persistent symptoms and analgesic drugs needed after the operation within a 3-month follow-up period. We used reference values of seminal quality established by the World Health Organization in 2010. The patient sperm was graded according to its motility; Grade A – rapid progressive motility, Grade B – slow or sluggish progressive motility, Grade C – nonprogressive motility, and Grade D – immotile. The minimum sperm concentration was 15 × 106 per mL; ≥4% of the morphologically normal forms were above the lower reference limit.We chose to only evaluate sperm volume, progressive motility, non-progressive motility, sperm concentration and morphology, since other parameters have been shown to have no significant effect according to previous literature.Testicular size was measured using an ultrasonography tool, which measured 3 ipsilateral testicle dimensions. The volume of the testicle was established by multiplying the dimensions by the standard coefficient of 0.52.,15 A horizontal 2 to 3 cm subinguinal incision was made below the external ring. The Camper and Scarpa fascia were then divided by means of electrocautery. Blunt dissection using the surgeon index finger was performed distally and proximally along the cord, deep to the Scarpa fascia, following which the cord could be easily grasped with a Babcock clamp. After that, the operating microscope was brought into the field. Under 10-power magnification, the external and internal spermatic fascia were opened. The veins were seen clearly under the microscope. All veins within the cord, except for the vasal veins, were doubly ligated by passing 2 6-0 Prolene ligatures beneath the vein. After the dissection, only the testicular arteries, cremasteric arteries, cremaster muscle fibers, nerves, lymphatic vessels, and vas deferens with its vessels remained.All patients underwent subinguinal microsurgical varicocelectomy by an experienced andrologist.t test. Primary outcomes were evaluated using multivariate analysis and area under the receiver operating characteristic (ROC) curve. P < .05 was considered to indicate a statistically significant difference.SPSS version 22.0 was used for all statistical analyses. The demographic data were presented as frequency, mean and standard deviation. The clinical outcomes, including sperm analysis before and after the operation, were compared using a paired Student Forty-four patients were included in the data analysis. The patients’ mean age was 33.3 ± 8.5 years, and the average preoperative NRS score was 7.6 ± 1.7. Other demographic characteristics of the study population are shown in Table Table Multivariate analysis revealed that severe varicocele grade  and the number of veins ligated  were significantly associated with changes in the NRS after surgery  compared to patients with a shorter duration of pain (17.7%). Therefore, both the nature and duration of pain may be independent predictive factors for the successful resolution of post-surgical pain. A prior study found that high-grade varicocele might predict the likelihood of pain resolution after surgery, which is consistent with our findings. These results align with the notion that more significant vein dilation may cause more severe heaviness in the scrotum, and therefore more varicocele-associated pain. Dilation of veins to a higher degree may also worsen pain mechanisms, such as discomfort from toxic metabolite reflux and neural fiber compression due to dilated veins.,20 On the other hand, however, Park et al found the opposite results in that varicocele grade was not correlated with pain resolution. Consequently, further comprehensive studies are warranted to elucidate this issue in future research.Researchers have also investigated additional predictive factors for surgical success in effectively alleviating post-surgery pain. Shindel et al found that younger age and increased varicocele grade were both predictive of varicocele pain.P = .017). The variability in the number of veins encountered during surgical procedures is linked to the clinical grade of varicocele. It is therefore compatible with the theory that the more veins encountered, the more testicular congestion would exist, and consequently the more scrotal pain would be caused. However, Elbardisi et al determined that while a significant improvement in postoperative pain was detected in patients undergoing microsurgical subinguinal varicocelectomy, the number of veins ligated intraoperatively did not have a significant effect (P = .81). This finding is in contrast to the results of our study. However, in their study, they categorized the patients into 3 groups according to the number of spermatic veins ligated during varicocelectomy , while we analyzed the exact number of veins ligated during the operation. Our results indicated that varicocele grade and varicocele vein ligation were correlated with pain after all other parameters were eliminated. In addition, the area under the ROC curve for changes in NRS and the total number of veins ligated showed that they were significantly predictive factors (0.869), meaning that the number of veins ligated was a strong predictor of changes in the NRS. Possible reasons for this difference could be because all of our patients received microsurgical varicocelectomy by the same experienced andrologist using a delicate surgical technique. In addition, we used the exact number of ligated veins instead of categorizing the participants into different groups. Furthermore, we recorded changes in pain according to the NRS, while the previous study only recorded whether there was pain improvement or not.The effect of the number of veins intraoperatively ligated has seldom been investigated in terms of pain resolution after surgery. The correlation between the extent of vein ligation during surgery and semen analysis outcomes was assessed by Shindel et al, who found a notable positive association between the number of veins ligated and the overall motility of sperm (,25 and most of our patient received semen analysis at 3 months of follow-up due to health insurance considerations. If we had extended the follow-up period for up to 1 year postoperatively, we believe that the results may have been different.As for semen quality, many studies in recent years have shown that microscopic varicocelectomy can improve semen quality. However, we found no significant improvement after microsurgical varicocelectomy at 3 months of follow-up (Table Our study has several limitations. First, this study included a relatively few number of patients and it was retrospective in design. In order to ensure homogeneity, we only analyzed a single experienced andrologist who was trained in microsurgery for male infertility at Weill Cornell Medicine in New York, United States. As a result, the number of enrolled patients was limited. Second, the pain assessment scale was used subjectively, which may have led to bias in the patient judgment of the intensity and quality of their pain, as every patient tolerance to pain can differ. Finally, we evaluated semen quality after a relatively short time after surgery due to health insurance considerations.Microsurgical varicocelectomy had a high success rate for scrotal pain and satisfaction. Severe varicocele grade and the number of veins ligated in microsurgical varicocelectomy were associated with postoperative pain improvement.Conceptualization: Chun-Yo Laih, Chi-Ping Huang.Data curation: Wei-Chun Huang.Formal analysis: Wei-Chun Huang, Fang-Yu Ku.Investigation: Fang-Yu Ku.Methodology: Chun-Ming Lai, Yun-Yi Wang.Project administration: Chun-Yo Laih, Chi-Ping Huang, Yun-Yi Wang.Resources: Chun-Yo Laih, Fang-Yu Ku.Software: Chun-Ming Lai, Hsu-Ning Hsu.Supervision: Chao-Tung Yang, Chun-Yo Laih.Validation: Hsu-Ning Hsu.Visualization: Chao-Tung Yang, Yun-Yi Wang.Writing – original draft: Wei-Chun Huang.Writing – review & editing: Wei-Chun Huang, Chun-Yo Laih.


Dear Sir,Haemorrhoidal disease (HD) is a common proctological disorder with a major impact on quality of life. Surgical excision is the gold standard approach to manage grade III and IV HD but postoperative pain is a frequent complaint . Indeed,p = 0.0035), while routine use of botulinum toxin, even if effective in the first postoperative days in terms of pain reduction , may not be cost-effective for pain relief alone because of its high costs. On the other hand, pain was reported to be consistently and significantly reduced after topical glyceryl trinitrate administration up to 7 days after the operation (p = 0.012) [Several pharmacological strategies for managing postoperative pain have been described in the literature . A recenp < 0.011 and p < 0.054, respectively) [Calcium channel blockers, such as nifedipine, have emerged in recent years owing to their effectiveness among the conservative approaches, but also in the postoperative period, especially after excisional anal surgery. Interestingly, although topical application of an ointment in patients who recently had surgery, particularly anal and perianal surgery, is usually not easy for the patient, Perrotti et al. reported that an ointment containing 0.3% nifedipine and 1.5% lidocaine may provide better pain control than 1.5% lidocaine alone at 6 h and 7 days after in patients who underwent open excisional haemorrhoidectomy (ctively) .2+ into the sarcoplasm of the smooth muscle, therefore promoting sphincter relaxation. As already mentioned, decrease of the internal sphincter spasm plays a role in pain relief when combined with topical analgesia. Moreover, nifedipine has also been shown to have anti-inflammatory properties as well as the ability to modulate the microcirculation leading to the decrease of the inflammation-related sphincter hypertonicity. Interestingly, the ointment appears to act locally on the IAS, with very limited detectable systemic absorption and with no relevant local or systemic adverse events, arrhythmias or significant ECG changes reported [Calcium channel blockers act by inhibiting the flow of Careported .It has been recently demonstrated that thrombosis of the mucocutaneous bridges is one of the main reasons for postoperative pain. Mesoglycan, a natural glycosaminoglycan compound , has been proposed as an antithrombotic, profibrinolytic, anti-inflammatory and antioedema agent. It exerts its antithrombotic activity through heparan and dermatan sulfate, which are thrombin inhibitors acting through complementary pathways, antithrombin III and heparin cofactor II, respectively. The profibrinolytic activity of mesoglycan is explained by the activation of annexin A2, which favours the cleavage of plasminogen by tissue plasminogen activator causing the release of the active form of plasmin able to cleave the fibrin.p < 0.001) resulting in a consistent and rapid return to work 7–10 days after surgery (p < 0.001), compared to the control group, which represents a relevant benefit of this treatment from a socioeconomic point of view [p < 0.05 and 3.3% vs 10.4% p < 0.005, respectively) [Both antithrombotic and profibrinolytic activities are carried out by reducing the concentration of plasma fibrinogen without affecting prothrombin time, partial thromboplastin time and antithrombin III levels. In fact, it has been shown to reduce pericapillary connective tissue oedema and capillary venule dilation in patients with primary venous insufficiency improving local conditions like arterial wall elasticity, transcutaneous oxygen perfusion and blood flow without any alteration of the coagulation parameters. Moreover, mesoglycan has been shown to reduce the levels of metalloproteinase-2 and metalloproteinase-9, tumour necrosis factor-α, soluble vascular cell adhesion protein 1, soluble intercellular adhesion molecule 1, and interleukin-6. A recent study demonstrated that patients who received mesoglycan postoperatively showed a significantly reduced rate of postoperative thrombosis (2.1% vs 11.1%) ( of view . These rAlthough the mechanism underlying postoperative pain is extremely complex and still not completely understood, the simultaneous use of topical application of 0.3% nifedipine and 1.5% lidocaine and the systemic administration of mesoglycan undoubtedly plays a key role, which will have to be clarified in future studies with a high level of evidence. Of course, the combination of analgesics, local ointments promoting re-epithelialization, and stool softeners is also necessary to improve the patient’s quality of life in the short term (Fig.


Cervicogenic headache is an often observed secondary headache in clinical settings, with patients who endure prolonged and persistent pain being particularly susceptible to mood changes. Currently, the Mulligan is one of the effective methods for CEH. However, there is a lack of evaluation about the strength and frequency of headaches, as well as the assessment of pain-induced emotions, in individuals with CEH using this particular procedure. Herein, we aimed to evaluate the effectiveness of the Mulligan maneuver from a multidimensional perspective of pain intensity and mood. A total of forty patients diagnosed with CEH who satisfied the specified inclusion criteria were recruited and allocated randomly into two groups: the control group and the treatment group, with each group consisting of twenty cases. The control group received health education, while the treatment group received the Mulligan maneuver once daily over a course of 10 treatment sessions.The clinical outcome of patients with CEH in two groups was assessed using the Visual Analog Scale (VAS), Hamilton Anxiety Scale (HAMA), and Hamilton Depression Scale (HAMD). Resting-state functional magnetic resonance imaging was employed to examine variations in brain function activities between the two CEH groups. Brain regions showing differences were identified as regions of interest and subsequently correlated with clinical behavioral measures using Pearson’s correlation analysis. The differences in VAS, HAMA and HAMD between the two groups of CEH patients were also statistically significant. The brain regions that showed differences in the ReHo scores between the two groups of CEH patients included the left cerebellum, the frontal gyrus, and the middle temporal gyrus. There was a positive correlation between the left frontal gyrus and VAS, HAMA and HAMD. The left middle temporal gyrus had a negative correlation with VAS, HAMA, and HAMD and the left cerebellum had a positive correlation with VAS correlation. The Mulligan maneuver may improve pain levels and have a moderating effect on pain-related negative emotions by regulating the function of relevant brain regions in CEH patients. CEH is a form of entrapment pain and explained its pathogenesis with the congregation theory. According to this theory, lesions in the structures innervated by the high cervical nerves  cause afferent injurious sensory messages from the high cervical nerves that are connected2. The prevalence of cervicogenic headache was estimated at 1%, 2.5%3 or 4 0.1%4 of the total population and up to 17.5% in patients with severe headaches3. The Prevalence is up to 53% in patients with post-whiplash headache5. The clinical diagnostic criteria include unilateral headache with evidence of cervical involvement by provocation of pain by neck motion or pressure on the neck; concomitant pain in the neck, shoulder and arm; and reduced neck range of motion, with or without other features6. Approximately 54% of CEH patients can develop chronic intractable pain. This can lead to anxiety or depression, seriously affecting the daily activities of patients7.Cervicogenic headache (CEH) is one of the most common secondary headaches in clinical practice and is caused by bony, disc, or soft tissue disorders of the cervical spine8. Based on a systematic review and meta-analysis, we found that manipulation can significantly improve the symptoms of head and neck pain in CEH patients and restore normal physiological function of the cervical spine without obvious side effects9. However, manipulation has not been reported to improve pain cognition or pain emotion in CEH patients. Recent studies have shown that the manipulation has a modulatory effect on the functional activity of certain regions of the brain. The manipulation can activate the function of the bilateral orbito gyrus, the middle frontal gyrus, the bilateral cuneate lobes, the bilateral inferior frontal gyrus, and the bilateral anterior cingulate gyrus. It increases connectivity between the sensory and executive cortex and inhibits its connection to the cognitive, visual, and memory cortex11.Recent studies have shown that manipulation can positively affect headache intensity, frequency, and cervical spine dysfunction in CEH patientsThe Mulligan manoeuvre is one of the best manipulations. Unlike traditional mobilisation, which relies solely on the therapist, Mulligan posited that by exerting pressure on the spinous processes in a weight-bearing stance, the facet joints would undergo a synchronized sliding motion in a parallel manner. At the same time, It requires the patient to move actively in order to achieve the perfect therapeutic effect. After more than half a century of clinical practice and technical improvement, it has formed a safe and effective mature treatment for cervical and upper thoracic spine disorders. The Mulligan maneuver is highly effective in the manipulative treatment of CEH.12. However, they do not take into account the fact that chronic pain results in feelings of anxiety or depression in patients. The Mulligan maneuver has been innovatively proposed not only for CEH pain symptoms, but also for emotional problems due to chronic CEH pain in our study. In order to demonstrate the therapeutic effect of the Mulligan manoeuvre for CEH, clinical rating scales were used to demonstrate its therapeutic effect on pain and its induced mood, and fMRI technology was innovatively introduced to demonstrate its therapeutic effect on pain and emotion-related brain areas.A systematic review have demonstrated the efficacy of the Mulligan maneuvre for CEH on clinical pain scales and cervical range of motion after treatmentThis study used a fully randomized, controlled, double-blinded, double-si-mulation research method. The study was in accordance with the Consolidated Standards of Reporting Trials (CONSORT) checklist guidelines. The study was registered in the China Clinical Trial Registration Center (Registration Number: ChiCTR2100054072 23/08/2021) and reviewed and approved by the Ethics Committee of the first affiliated hospital of Zhejiang Chinese Medical University with approval number (Ethics Number: 2021-K-491–01 19/07/2021). All subjects signed an informed consent before the study. All methods were carried out in accordance with the tenets of the Declaration of Helsinki as well as the relevant guidelines and regulations.Eligibility criteria: All participants were diagnosed with CEH according to the diagnostic criteria for CEH in the third edition of the International Classification of Headache Disorders (ICHD-3) in 2018. They were examined at the outpatient clinic of the first affiliated hospital of Zhejiang Chinese Medical University from January 2022 to December 2022.Inclusion criteria were as follows: CEH pain intensity 3–8 on 10-point pain scale; Cervical spine dysfunction; Cervical motion reduction; Headache after neck pain; Patients with neck tightness and limited range of motion.Exclusion criteria: History of cervical spine surgery or history of severe cervical spine trauma; Combination of severe osteoporosis, bone tumor, and bone tuberculosis; Combination of cardiovascular, cerebrovascular, digestive, hematologic and other serious medical diseases; Combined with mental diseases, such as claustrophobia and mental retardation; Pregnant or lactating women; People with language comprehension and expression disorders; Contraindications to magnetic resonance, such as metal foreign bodies in the body; and pacemaker implantation.Dropout Criteria: Cases that have been enrolled but have not completed the clinical program should be considered to have dropped out in the following cases: The patient withdraws from the study on his/her own; Subjects with poor compliance cannot come for treatment as required, and the patient does not cooperate; The treatment is effective during treatment but cannot complete the entire observation program.; The treatment is effective during treatment, but the patient cannot complete the entire observation program; The subject does not withdraw from the study but no longer accepts the treatment and loses the visit; In the course of the study, other diseases occur, and the treatment is stopped for more than one week in the middle of the study.First, all participants signed an informed consent form with the right to withdraw at any time. After recruitment, a qualified therapist will explain the study procedures and collect demographic data at the initial assessment following recruitment. Throughout the study, confidentiality will be maintained.Participants were assigned to the Mulligan manipulative therapy group or the health education group in a 1:1 ratio. Randomisation was computer generated centrally by the Clinical Evaluation Centre of the first affiliated hospital of Zhejiang Chinese Medical University, China. The randomization method achieved allocation concealment using randomization envelopes that were opaque and sealed randomization envelopes. The allocation scheme of two groups was placed in envelopes with the serial number of the group on the outside and the group printed on the inside of the envelope. The envelopes with numerical identifiers were sequentially unsealed in accordance with the order of patients who were still not being attended to and the administration of treatment was carried out according to the specified interventions outlined within the envelopes and treatment was administered according to the interventions requested within the envelopes. The treatment regimen received by each subject was determined by the generated randomized sequence. The Clinical Evaluation Centre of the first affiliated hospital of Zhejiang Chinese Medical University was responsible for the efficacy evaluation to achieve blinding of patients and statistical evaluators. A sample expansion of 20% was proposed, given the possibility of attrition in the study  device to measure the pressure exerted by the operator. FingerTps is worn on the operator’s thumb and the information collected about thumb pressure is transmitted in real time to a computer via a wireless transmitter in the finger sleeve, which allows the operator to adjust the force using a display screeness Fig. .The specThe research group used WeChat group building to carry out the intervention with the CEH patients. On the day of enrolment, the CEH patients’ pain intensity and pain emotion were evaluated by an independent evaluator. After the evaluation, the staff will send the health education content to the we chat group on a regular basis, which includes the following information such as the definition of CEH, the primary causes of diseases, daily preventive measures, lifestyle habits, and dietary recommendations. It emphasizes the importance of avoiding excessive strain, exposure to wind and cold, and prolonged usage of electronic devices such as computers and mobile phones. However, it does not encompass the treatment of cervical vertebrae or exercise methods for rehabilitation within the scope of health education. The process is considered complete when the patient responds to the message in the group. Staff can call the patient to complete the reading to respond if the patient does not respond to the message. The message is sent out once a day, and ten times for each course of treatment. After one treatment session, the CEH patients were reassessed by an independent assessor for pain intensity and pain sensation, and MRI scans were performed immediately.A GE Discovery MR750 3.0T MRI scanner was used for imaging. The subjects underwent structural and BOLD functional imaging, and the scanning range was from the frontal-parietal to the base of skull, covering the entire brain. The scanning parameter settings: The structural image was acquired using the weighted fast scrambled phase gradient echo sequence technique. This allowed for acquiring the axial weighted images of T1W1 and T2W1. The scanning parameters were as follows: a repetition time of 1900 ms, a field of view set to 256 × 256 cm, an echo time of 2.26 ms, a matrix size of 256 × 256, and a scanning time of 7 min. Additionally, BOLD functional imaging was performed using the gradient echo sequence technique with a single excitation planar echo to acquire the information function. Scanning parameters: The repetition time is 2000 ms, the time point is 240, the echo time is 30 ms, the number of layers is 30, the layer thickness is 5 mm, the matrix is set to 64 × 64, the field of view is set to 256 × 256 cm, the flip angle is 90°, and the scanning time is 8 min.Preprocessing was performed using the Statistical Paretric Mapping12 (SPM12) software package based on the MATLAB R2014a platform, which mainly includes removing time points, temporal layer correction and head movement correction, spatial normalization, de-linearization drift, and noise filtration. After preprocessing, the data were used to calculate the local consistency of each voxel with its neighboring 27 voxels in the same time series by applying Kendall’s concordance coefficient. After preprocessing, Kendall’s concordance coefficient was applied to calculate the local coherence between each voxel and its neighboring 27 voxels in the same time series. Subsequently, the whole-brain ReHo images of subjects’ whole brains were generated. Finally, the whole-brain ReHo images were spatially smoothed using a smoothing kernel with a full-width and half-height of 6 mm to filter out the noise.The primary outcomes were assessed by an assessor blinded to group allocation and intervention in the department at each time point, such as at baseline and after ten sessions of treatment. The secondary outcomes were assessed by a technician trained in magnetic resonance operation, but blinded to group allocation and intervention after patients had completed ten sessions of treatment.14. Participants were asked to rate the intensity of pain on a 10 cm scale, where0 being ‘no pain’ and 10 being ‘maximum pain that is unbearable’. This is a valid and reliable (ICC = 0.60–0.77) instrument for measuring CEH pain intensity and was administered at baseline and after ten sessions of treatment.CEH pain: A 10-point visual analogue scale (VAS) was used to measure the intensity of CEH pain15. A scale of psychological and physical anxiety was completed by participants, ranging from 0 to 4, indicating no symptoms to extremely severe symptoms. Hamilton Depression (HAMD) scale was used to assess the depression symptoms15. Symptoms were scored on a five-point scale, where 0 to 4 ranged from no symptoms to extremely severe symptoms and included 7 subscales: anxiety/somatisation, weight, cognitive impairment, diurnal variation, blockage, sleep disturbance, and hopelessness.The test–retest reliability was between 0.65 and 0.91 ,and the construct validity was good.CEH emotion: Hamilton Anxiety Scale (HAMA) scale was used to assess anxiety symptoms16. ReHo combined with clinical variables has been used to study pain and psychiatric disorders.The local brain functional activity: Regional Homogeneity (ReHo) is a measure of the local coherence of spontaneous brain activity and is sensitive to the following abnormal local functional connectivity of brain regions17, the sample size estimation formula for comparing the two sample rates is as follows:a/2 = Z0.05/2 = Z0.025 = 1.96 (From Z table) at type I error of 5%; Zβ = Z0.20 = 0.842 (From Z table) at 80% power, d = effect size = difference between mean values.This study was a randomized controlled trial where in two groups were established based on the pre-experiment outcomes. The sample size for this study was calculated based on the primary outcome of visual analogue scale. According to the literatureThe allocation of participants into the test and control groups followed a 1:1 ratio. Each group initially consisted of 16 cases, and the sample size was increased by 20% to account for potential factors including loss of visits and attrition. Consequently, a minimum of 20 cases per group was required for the study subjects.P < 0.01 for voxel level, P < 0.05 for clusters). The ReHo values of different brain regions were extracted and analyzed by Pearson correlation analysis with clinical behavior indices , and the differences were considered statistically significant at P < 0.05.Data were statistically analyzed using the SPSS26 software package (SPSS Inc. USA). Measurement data was described using P > 0.05)  Table .Table 1Tp = 0.00) in the Mulligan maneuver therapy group more than in the health promotion intervention group  improve (p = 0.03) and HAMD score 1.62 (95% CI 0.3606 to 2.879) improve (p = 0.01) in the Mulligan maneuver therapy group more than in the health promotion intervention group  and the Hamilton Depression (HAMD) scale scores of the two groups were found to follow a normal distribution. After ten sessions of treatment, HAMA score 1.08 (95% CI 0.08816 to 2.072) improve (P < 0.01) , HAMA , and HAMD  scores in the treatment group , HAMA , and HAMD  score. However, no significant correlations were found between HAMA  and the HAMD scores   Fig.  Table 3P < 0.01 18. A previous study has shown that CEH patients suffer from physical pain, cognitive dysfunction, and psychological distress. Our research supports this view. In addition to the higher VAS score, the HAMA and HAMD score of the CEH patients was also higher than that of the normal patients. This is an indication of depression or anxiety. Previous studies have demonstrated the effectiveness of manipulative therapy in terms of headache index, trigger point pressure pain, neck function assessment index, and range of motion in CEH19, and the evaluation of pain-induced emotions is less involved. The results showed: the VAS score, the HAMA and HAMD score scores decreased after the Mulligan maneuver treatment and were better than in the control group. This suggests that the Mulligan manoeuvre has a therapeutic effect on the intensity of pain, and also has some alleviating effect on pain-induced anxiety or depression.Chronic persistent pain can lead to cognitive abnormalities in pain, subsequently causing anxiety or depression. Recent research shows that CEH patients suffer from the physical discomfort of pain, cognitive dysfunction, and psychological dysphoria20. Our study is an innovative use of fMRI technology to explore the functional areas of the brain where the Mulligan maneuver has therapeutic effects, thus providing a scientific basis for the Mulligan maneuver treatment of CEH. This method has a certain uniqueness.Moreover, an additional study has shown that CEH patients have synergistic increases or decreases in neuronal activity in localized brain tissue, suggesting that CEH involves pathological changes in multiple brain regions associated with regulating affective cognition21. In conjunction with the results of this project, we believe that CEH patients exposed to repeated painful stimuli who are subjected to recurrent noxious stimuli experience specific aberrations in the perception and modulation of pain-related data. Several below-threshold pain tends to be amplified and processed. This is related to the fact that long-term chronic pain tends to cause damage to the frontal gyrus and emotional cognitive decline in patients with CEH. The Mulligan maneuver can somewhat improve the functional changes in the frontal gyrus and other brain regions and alleviate pain sensitivity due to cognitive decline.Herein, we found statistically significant changes in the function of frontal, middle gyrus, and middle temporal gyrus brain regions in CEH patients using the Mulligan maneuver. Furthermore, we identified correlations between these changes and clinical behavioral indicators. The middle frontal gyrus is a part of the frontal lobe that is thought to play a crucial role in regulating affective cognition, including memory and executive function. It is important to reduce pain sensitivity through affective cognitive modulation22 study has found that cerebral blood flow in the middle temporal gyrus was reduced after treating CEH patients and Mohamadi23 study also shows that Manipulation affects central sensitization which can change brain metabolic map. This is consistent with our findings. So we hypothesise that by using the Mulligan technique, sensory inputs can be sent to the CNS. Perhaps these additional sensory inputs play a role in these inhibitory effects and we believe that the Mulligan maneuver can regulate the pain level and play a significant role in pain-induced emotions.The middle temporal gyrus is also a target of the Mulligan maneuver. Several studies have reported that the middle temporal gyrus is associated with emotional and sensory processing, including depression, anxiety, and pain ratings. Furthermore, it has been observed that enduring unpleasant emotional experiences resulting from pain can potentially create alterations in brain functionality. Herein, ReHo scores in the middle temporal gyrus were reduced and negatively correlated with VAS, HAMA, and HAMD, possibly due to the Mulligan maneuver’s protective inhibitory effect on the middle temporal gyrus. MEDINA24. The cerebellum plays an important role in processing pain sensations, as signal inputs from the A-fibre and C-fibre nociceptors reach the Purkinje cells of cerebellum25. The cerebellum is closely connected to the brain’s limbic system, amygdala, hippocampus, anterior cingulate gyrus, and frontal and temporal lobes. According to our findings, we believe that the Mulligan maneuver adjusts the neural circuits between the cerebellum and the brain by modulating the functional areas of cerebellum, thereby activating the corresponding functional areas of brain and ultimately realizing the intervention of pain emotion.Additionally, we found that the manipulation had a benign moderating effect on changes in cerebellar function and a positive correlation between this change and VAS scores. Previous studies have focused on the cerebral cortex at the expense of cerebellar function. In a rat model of neuropathic pain, cerebellar activity was positively correlated with the development of neuropathic pain and prognosisNevertheless, it is important to acknowledge the constraints of this investigation, namely the relatively small sample size and the utilization of imaging data solely for the purpose of examining alterations in regional brain functionality among CEH patients. Consequently, further investigations need to be conducted to increase the sample size and explore the underlying mechanisms pertaining to the network connectivity of local cerebral activity.Herein, we found that the Mulligan maneuver can improve pain levels and regulate pain-induced negative emotions by modulating the function of relevant brain regions in CEH patients.


Cutibacterium acnes colonization in intervertebral discs (IVDs) in patients with lumbar disc degeneration (LDD) and low back pain (LBP), but the meaning of these findings remains unclear. Being aware of this knowledge gap, we are currently conducting a prospective analytical cohort study with LBP and LDD patients undergoing lumbar microdiscectomy and posterior fusion. The IVDs samples collected during the surgeries are subjected to a stringent analytical protocol using microbiological, phenotypic, genotypic, and multiomic techniques. Additionally, pain-related scores and quality-of-life indexes are monitored during patient follow-up. Our preliminary results for 265 samples (53 discs from 23 patients) revealed a C. acnes prevalence of 34.8%, among which the phylotypes IB and II were the most commonly isolated. The incidence of neuropathic pain was significantly higher in the colonized patients, especially between the third and sixth postoperative months, which strongly suggests that the pathogen plays an important role in the chronicity of LBP. The future results of our protocol will help us to understand how C. acnes contributes to transforming inflammatory/nociceptive pain into neuropathic pain and, hopefully, will help us to find a biomarker capable of predicting the risk of chronic LBP in this scenario.In the last decade, several studies have demonstrated  Low back pain (LBP) is a highly prevalent complaint among the population. It has several consequences for the patient and for society, such as physical and psychological limitations, drug abuse, absenteeism from work, and the potential to overload social security and health systems ,2,3. It Cutibacterium acnes, which has a prevalence rate of around 40% [C. acnes in this scenario.In the last decade, advances in molecular identification and microbiological culture techniques have redirected the researchers’ attention to the isolation of low-virulence pathogens in different musculoskeletal conditions, such as aseptic failures of surgical implants and intervertebral discs (IVDs) degeneration ,16,17,18ound 40% ,20,21. GC. acnes colonization [C. acnes, but these findings are not unanimous among studies [C. acnes. These authors integrated the presence of the pathogen with mechanical factors, such as the occurrence of fissures in the endplates, within what they called the unified hypothesis of disc degeneration [C. acnes in IVD cell cultures on the expression of IL-1β and other host defense molecules related to the neo-innervation of the annulus fibrosus and the degradation of the extracellular matrix (ECM) of IVDs [C. acnes strain; some biofilm-producing phylotypes use this feature to remain inert to defense cells within IVDs, while others produce ECM degradation enzymes in IVDs and activate inflammatory cascades through the Toll-like receptor system [Studies evaluating Modic changes (MCs) are the most common in relating LDD to nization ,23,24,25nization ,27. Subs studies ,28,29. Rneration . Capoor  of IVDs . Other ar system ,34,35,36C. acnes in IVD de-generation pathways and the activation of inflammatory cascades, so far, the available literature has not fully explained the mechanisms related to the generation and/or chronification of LBP in patients with LDD. There is a dearth of studies that aim to monitor the evolution of patients’ pain complaints, especially after IVD collection and not just at the time of enrollment for microbiological investigation. There are no standardized or reproducible protocols, so the data produced by analytical cohorts can barely be used in trustworthy reviews and meta-analyses. There are also few alternatives to compensate for the lack of “normal” control IVDs that, despite bacterial colonization, present the physiological changes of aging, which will vary according to genetics and an individual’s choices throughout their life.Although there is growing evidence pointing to the active role of ClinicalTrials.gov, has been validated, and is already in progress.Aware of these limitations, our research group designed a prospective cohort study for the follow-up of patients with LBP and LDD. In addition to the control of clinical variables before and after sampling , the design of this cohort also houses an analytical study that brings together microbiological, molecular, and multiomic techniques in an unprecedented way . This prGiven the topic’s relevance, this manuscript aims to present the preliminary micro-biological results of this research and to correlate them with the clinical profile of the patients being followed up.This cohort study integrates clinical and analytical data and is in progress at the Spine Surgery Center of São Matheus Hospital, in partnership with the Gaffrée and Guinle University Hospital and the Laboratory of Anaerobic Biology, at the Institute of Microbiology Paulo de Góes (IMPG) of the Federal University of Rio de Janeiro (UFRJ).Patients with LBP for at least 3 months and findings confirming LDD on MRI were recruited and selected for surgical treatment through microdiscectomy and lumbar fusion. The procedures were performed in a single hospital by the same team of surgeons. All patients included in the study were informed about the research and freely agreed to participate before signing the Informed Consent Form for the study. The selection criteria for the study are listed in The patients were monitored by a team of specialists in pain and/or spinal surgery for at least 3 months before surgery and for the first 6 months after surgery. During patient recruitment and follow-up, we collected demographic, clinical, and imaging data . Only thIntravenous antibiotic prophylaxis was performed exclusively during the surgery for all the patients , as is the hospital protocol of cutaneous asepsis using 2% chlorhexidine gluconate degerming solution and 0.5% alcoholic solution of chlorhexidine gluconate.During surgery, five tissue fragments were collected for each IVD addressed. A set of sterile surgical tweezers was used for collection, with one set being used for each tissue fragment. Immediately after collection, the clamp with the sample was handed over to a member of the laboratory who was also present in the operating room during the procedure. Each sample was inoculated into a flask containing thioglycolate culture medium  containing 20 glass beads in each tube. After sampling, the vials containing the clinical specimens were kept at room temperature and were transported to the laboratory of Biology of Anaerobes at the Federal University of Rio de Janeiro (UFRJ)  within a maximum period of 2 h.®, Curitiba, Brazil) for 15 s. All tubes were kept in a bacteriological incubator (from 35 °C to 37 °C), and after 24 h, the first subculture was performed. Using a 100 µL bacteriological loop, aliquots of thioglycolate were removed and seeded: one onto a blood agar base and another on anaerobic blood agar. The first plate was incubated under a capnophilic atmosphere, and a second plate was kept in strict anaerobiosis using an anaerobic jar or Glove Box . The plates were read after 24 h, and, in case of growth, the colonies were identified in the MALDI-TOF MS . In the absence of growth, they were reincubated, and a new reading was performed after 72 h. The same procedure was used for all of the thioglycolate vials . The thioglycolate tubes containing the clinical specimens were kept under incubation (35 °C to 37 °C) for at least 14 days. The subculture procedure was performed after 72 h and then every 3 days, with the last being performed on the 14th day of incubation in the same solid culture media and atmospheres used in the first 24 h.The tubes containing IVD fragments undergo vortexing  and r-16S DNA analysis using the Multiplex Touch-Down PCR technique (species-specific and Filotyping PCR), respectively.The analyses of the samples were carried out sequentially according to the performance of the surgical procedures in the selected participants. Once the pathogen in the culture media has been identified, we proceed with its phenotypic and genotypic characterization by using MALDI-TOF MS (Bruker BiotyperC. acnes colonization (metabolomics). Variables distributions in the negative and positive to C. acnes groups were compared appropriately by the Fisher’s exact test or Mann–Whitney tests.We perform multiomic analyses for: (1) the identification of prokaryotic proteins that may be acting as molecular patterns associated with pathogens (PAMPs) or damages (DAMPs) in the host response (proteomics) and for (2) the definition of a metabolomic signature for patients with LBP who have LDD associated with At the time of writing this manuscript, the microbiological analyses of 265 lumbar IVD samples obtained from 23 patients  with a mean age of 46.5 years had been completed . No clinical disease was reported with a frequency greater than 50% . Obesity was identified in 43.5% of the patients (seven with grade I and three with grade II). Smoking was reported by 39.1% of the patients (consumption of at least one cigarette/day over the course of 1 year), and 60.9% declared themselves to have a sedentary lifestyle . The patients’ baseline characteristics are listed in C. acnes was isolated in discs from 34.8% of the patients and more frequently among men (62.5%). The number of samples collected from each patient ranged from 5 to 20, totaling 265 samples, with an average of 11.5 samples collected per patient. In 160 samples from 15 patients, no positive samples were found. The 8 positive patients had 105 samples together, of which 79 were positive. Therefore, it is estimated that 24.8% of samples from positive patients do not show a positive result, showing the need to investigate several samples per patient (at least 1/0.752 = 1.3 samples from each patient). Therefore, it is recommended to collect at least 2 samples from each patient for this investigation. The number of positive samples from each positive patient ranged from 2 to 20, averaging 9.9 positive samples from each positive patient. C. acnes from the IVD samples.Culture results are available for the 265 IVD samples . C. acnes, phylotyping was not possible due to the death of the strains. Phylotypes IB and II were found the most frequently in the colonized patients, being isolated in five and four patients, respectively; these two phylotypes jointly colonized 42.9% of the positive samples. The IA1 and IA2 phylotypes were isolated less frequently, being in mutual association in one patient and associated with the IB and/or II phylotypes in three other patients. In one of the patients colonized by p-values of Mann–Whitney test lower than 5%). None of the patients had a motor deficit, and neuropathic pain was only identified in one of them (score greater than 4 on the DN4 questionnaire) during the preoperative clinical evaluation. Regarding the baseline characteristics , there was no significant difference between the groups with positive and negative cultures . There was also no significant difference between these two groups in the preoperative Oswestry Disability Index (ODI) and EuroQol (EQ-5D) Quality of Life Scores .All of the patients had LBP , and an indication for surgical intervention was the failure of conservative treatment. The mean duration of symptoms before surgery was 12.1 months , which was higher among the patients with sedentary lifestyles, patients with SAH, and those with mechanical pain . There were no clinical or operative complications for the patients included in this part of the study.In all of the patients, the surgical technique used was the same , with only the number of IVDs addressed in each patient varying . The mean duration of the procedures was 3.7 h , with an average of 1.6 h/level . Regarding the duration of surgery and the number of IVDs addressed per patient, there was no significant difference between the groups with positive and negative cultures in the disk . Time of opioid usage was significantly higher in the colonized patients , as was the time off work .The mean length of hospital stay was longer in the patients with positive IVD cultures  than in the patients with negative cultures , but this difference was not statistically significant . However, the VNS distributions from the third to the sixth months show a significant difference in the observed improvement between the two groups, being smaller in the positive group . C. acnes colonization also seems to have influenced the occurrence of neuropathic pain in the postoperative period, with a significantly higher incidence among the patients with positive cultures, as seen in p-values < 0.05). The neuropathic pain statistics at different moments during clinical follow-up are displayed in Despite an overall improvement in VNS scores after surgery, when comparing the pain levels in patients with and without positive cultures, this improvement was not significant before the third postoperative month .According to the functional assessment using ODI, we noted that there was an improvement in the global scores between the preoperative period and the sixth month after surgery, but this evolution was not statistically significant between the groups with and without positive cultures . However, comparing the groups, we noticed that the presence of bacteria did not significantly interfere with the benefit of treatment before the sixth postoperative month . From the assessments of the quality of life using the EQ-5D, the surgical intervention had a significant and positive impact on all of the assessment domains except for the self-care domain .Just over half of the patients had MCs on preoperative MRI in at least one of the surgically approached levels (52.2%). Among the colonized patients, a significant association was identified between C. acnes in disc prevalence (34.8%) and MC association (66.7%) close to the rates reported in the literature. The largest systematic review and meta-analysis ever published on the subject showed a prevalence of 28.7% in 1454 patients with disc degeneration [C. acnes from IVD cultures, which hinders the performance of complementary analyses of the pathogen, such as strain phylotyping.Our protocol revealed a neration . This reC. acnes has different and distinct evolutionary lineages, with the designated phylotypes IA1, IA2, IB, IC, II, and III being based on Multilocus Sequence Typing and Whole Genome Sequencing [C. acnes and participate in the LBP chronification process.quencing . Each phquencing ,39. Rollquencing ; this phquencing . Moreovequencing . HYL hasquencing ,43; phylquencing ,44. In aquencing . Our preC. acnes may be acting in the modulation of pain generation and chronicity mechanisms. C. acnes has already been linked to elevated levels of neurotrophins related to the penetration of nociceptive neurons into the deeper layers of the annulus fibrosus in cell cultures [C. acnes colonization of IVDs chronically exposes the newly formed nociceptive neuron endings to pain triggers, resulting in chronic LBP. Future studies on these and other possible mechanisms involved in the chronicity of LBP in this type of patient profile represent further challenges. Mapping the phylogenetic epidemiological profile of IVD colonization in LDD and monitoring the responses of the host’s immune system of the host for each manifested virulence factor are the next steps.Unprecedentedly, our study continues to monitor patients with LDD after IVD collection, and among the differences observed in the first part of our results, the one that caught our attention the most was the change in the pain patterns presented by the patients over the postoperative period. Among the colonized patients who had mechanical and/or nociceptive pain in the preoperative period, 37.5% manifested characteristics of neuropathic pain up to the third month after surgery, with an increase in this proportion to 87.5% by the sixth postoperative month. These data should direct studies to the mechanisms through which cultures  as well cultures ,46,47,48cultures . Freemoncultures . From thC. acnes, metabolomic analyses have been carried out to search for a metabolomic profile for chronic LBP related to the pathogen and LDD. Another multiomic analysis that has been carried out with isolated strains is proteomics analysis, whose main goal is to identify bacterial proteins in different IVD phylotypes that may be acting as inflammatory and nocigenic triggers.A variety of biological , psychological , and social  factors are involved in conditions that generate chronic pain . These fC. acnes is a pathogen that causes a low-grade symptom infection which is difficult to be diagnosed, especially in our country. This is the first study to demonstrate the isolation of C. acnes and phylotypes in the disc content of patients with LBP. With the increasing number of cases involving this pathogen, particularly in orthopedic surgeries related to nonspecific infection, low immune response, and chronic pain, there is an urgent need for new biomarkers to improve not only the presence of C. acnes but its relation to the infectious disease. As a result, the “omics” approach can aid in the development of new diagnostic approaches for detecting C. acnes and assisting clinicians in infection and chronic pain in their patients.The use of multiomic techniques, in addition to culture isolation techniques, is the most modern strategy for identifying biomarkers related to bacterial activity ,58,59,60


No strong and consistent variables to predict outcome after pain rehabilitation have been reported in patients with chronic musculoskeletal pain. The aim of the present study was to clarify if baseline variables could predict successful outcome after a unique, individualized, physiotherapist-led rehabilitation of nine sessions.  In 274 individuals with severe chronic musculoskeletal pain, the risk ratio (RR) and 95% confidence intervals (CIs) were estimated for potentially predictive baseline variables on successful outcomes of pain management, overall health, and pain rating.  Statistically significant results show that patients rating moderate or severe baseline pain were in both cases 14% less likely to improve pain management compared to patients rating mild baseline pain . Patients with the shortest pain duration were 1.61 times more likely to improve overall health  compared to patients reporting the longest pain duration (>5 years). Patients reporting anxiety/depression or severe pain were in both cases 1.48 times more likely to improve overall health compared to better baseline presentations . Patients with regional/generalized pain were 36% less likely to rate pain reduction  compared to patients rating localized baseline pain. Of 17 potentially predictive baseline variables, four reached statistical significance for at least one of the three outcomes; although none of them for all three outcomes.  Of 17 potentially predictive baseline variables, mild pain ratings, short pain duration, and localized baseline pain were statistically significantly associated with improvements after individual, physiotherapist-led rehabilitation for patients with chronic musculoskeletal pain. This suggests that this type of rehabilitation probably should be offered early in the pain process. Reporting anxiety/depression or severe pain at the baseline did not hinder the improvements of overall health. Chronic musculoskeletal pain (CMP) is a persisting or reoccurring pain lasting more than three months, originating from musculoskeletal structures such as joints, bones, muscles, tendons, or from multiple body areas and/or components, such as regional or widespread pain –4. AboutRecommended treatments for chronic pain are combinations of interdisciplinary interventions with psychological, educational, physical, and occupational components, often delivered in group format over weeks or months –10. As yEven if interdisciplinary interventions, as well as one-to-one physiotherapy approaches can be effective, not all patients benefit from these interventions. Therefore, it is important to identify the patients that benefit the most from different interventions . An impoThe aim of the present study was to analyze if baseline variables could predict successful outcomes after individualized, one-to-one, physiotherapist-led rehabilitation for patients with CMP who were refractory to preceding similar treatments. The outcomes were measured as follows: (i) ability to manage overall life circumstances, (ii) ratings of perceived overall health status, and (iii) ratings of pain.inclusion criteria were as follows: chronic (>3 months) musculoskeletal pain and 18 years of age or older. The exclusion criteria were as follows: acute psychiatric illness or acute crisis, urgent social or economic difficulties, present alcohol or drug abuse or psychological consequences deemed to hinder the improvements of physiotherapeutic interventions. The exclusion criteria were assessed by MD or a psychologist. The patient cohort has been described in detail in a previous study [Patients with CMP in the present study were consecutively included in the rehabilitation program between Jan 1st 2014 and 20th Nov 2018, according to a structured, written routine and according to regular clinical care. The patients had been referred to physiotherapy within a specialized pain unit in Sweden due to unresolved pain problems. Most patients were referred from primary care. In total, 486 consecutive patients were referred to the physiotherapy department and eligible for inclusion. The us study .82 patients lacked follow-up data due to administrative reasons/changes during the 5 years of data collection. For example, questionnaires were changed or exchanged50 patients were transferred to other health care levels  before the follow-up39 developed new diseases requiring specific medical care during the program41 discontinued the program see .Out of the 486 eligible patients, not all were available to be included in the final clinical cohort. This was due to the following reasons:In the final cohort, 274 patients , patients with CMP  median 7/10, pain duration median 2.8 years) and moderate disability, were included  see Tab.In the PT-PRP, all patients received an initial evaluation consisting of a medical history, a physical examination, and questionnaires. Further, the PT-PRP consisted mainly of patient education, sensorimotor training, physical activity advice, and interventions aiming at improving structures and functions see . The mosPatients answered questionnaires prior to the rehabilitation, at discharge and one year after discharge, using patient reported outcome measures (PROM). The PROMs used in the PT-PRP, and hence in the present study, were chosen based on clinical experience and the literature –26. The One question on ability to manage overall life circumstances according to the Swedish Quality Registry for Pain Rehabilitation (SQRP) is as follows: “has your rehabilitation influenced your ability to manage overall life circumstances?,” 1–5, 1 = much worse, 2 = worse, 3 = no change, 4 = improved, and 5 = much improved. Successful outcome after rehabilitation was defined as rating “improved” or “much improved” at discharge .Ratings of perceived overall health status were evaluated with EQVAS from the EuroQol five-dimension scale . Assessments of perceived health were rated on a scale from 0 = “worst health imaginable,” to 100 = “best health imaginable” . SuccessPerceived pain during last week according to NPRS, 0–10, 0 corresponding to no pain, 10 corresponding to worst pain imaginable . SuccessThe three main outcomes were as follows:The patients' ratings of the question on “ability to manage overall life circumstances,” pain, and perceived health status at discharge are presented in detail in a previous study by Trulsson Schouenborg . In shorNPRS was categorized into mild, moderate, and severe pain categories .DRI was categorized into three categories according to the tertiles of the DRI results in the present cohort , 33.EQVAS was categorized into three arbitrary categories  based on our results of very few individual rating EQVAS 80–100 at the baseline.The single question, “What is your opinion on your ability to reduce your pain/ailment,” was aggregated into three categories.The questions on physical exercise, leisure exercise, and sedentary time were respectively divided into three categories.The single question on anxiety/depression in EQ-5D, 3L, and 5L was dichotomized into either “reporting NO anxiety/depression” (=answer no. 1 + 2 in EQ-5D 3L and in EQ-5D 5L) or into “reporting anxiety/depression” (=answer no. 3 in EQ-5D 3L and no 3 + 4 + 5 in EQ-5D 5L) .“Number of sessions during the rehabilitation-period” was categorized into three categories according to the tertiles in the present cohort and also since the literature shows unknown dosage .“Number of different types of interventions” was categorized according to the tertiles obtained in the present cohort.Potentially predictive baseline variables including categorization are presented in Our reasons for using categories for pain duration and “ability to reduce pain” were that they were categorized already in the questionnaire. BMI and NPRS have clinically meaningful categories, making it easier to interpret in the clinical situation. Variables of age, DRI, and EQVAS could have been included as continuous variables; however, due tothe relatively small study sample, we made the decision to categorize them to increase power.Data in the present study were retrieved from a previous study, and all patients were subject to “usual care” . Informers) were used.Descriptive statistics were used to analyze frequencies and distribution, and in measurements considered to be ordinal scale data, median, minimum–maximum, and quartiles were used. In analyzes of within-group comparisons, nonparametric statistics were used to test for differences (Wilcoxon signed rank test). To calculate the intercorrelation between main outcomes, nonparametric bivariate correlation and Spearman's correlation coefficient  was calculated using modified Poisson regression, i.e., Poisson regression with a robust error variance, using the PROC GENMOD procedure and the repeated subject statement . In a firs > 0.4. Hence, all three outcomes were included in the analyzes as independent outcomes.No intercorrelations between the three outcomes regarding change in outcomes (between start and discharge) did exceed p values less than 0.05 were considered statistically significant.Statistical analyzes for between-groups comparisons and nonparametric correlations were performed using IBM SPSS Statistics 25, whilst modified Poisson regression was performed using SAS, version Enterprise 8.3 (SAS Institute Inc.). univariate analyzes for the three outcomes: “ability to manage overall life circumstances”, EQVAS, and NPRS.Nine of the suggested 17 predictive baseline variables included in the analyzes showed statistically significant prediction on the outcome in the univariate analysis were for the outcomes:“ability to manage overall life circumstances”: NPRS and classification of localized/regional/generalized painEQVAS: anxiety/depression, duration, and NPRSNPRS: EQVAS, DRI, age, classification of localized/regional/generalized pain, amount of weekly physical exercise, information on if assessed by a team or by solely a physical therapist before start of the program, and duration see .The variables that showed statistically significant RRs in the multivariate analysis, the statistically significant predictive variables from the univariate analyzes were included, and the RR and 95% CI for each of the three outcomes showed the following result:In the Patients with pain ratings of NPRS 6–7 or 8–10 at start of rehabilitation were in both cases 14% less likely to improve in “ability to manage overall life circumstances,” as compared to those rating NPRS 0–5  see .Patients reporting anxiety/depression at start of rehabilitation were 1.48 times more likely to improve in overall health status (EQVAS) as compared to those who did not report anxiety/depression at the baseline . Likewise, patients rating severe pain (NPRS 8–10) at start of rehabilitation were 1.48 times more likely to improve in overall health status (EQVAS) as compared to patients rating mild pain (NPRS 0–5) , while patients reporting the shortest pain duration (3 months to 1 year) were 1.61 times more likely to improve in overall health status (EQVAS) as compared to patients reporting pain duration >5 years .Patients being diagnosed with regional or generalized pain were 36% less likely to improve in pain rating (NPRS) at discharge as compared to patients diagnosed with localized pain at the baseline  see .n < 5. Thus, these three results were not used in step two of the analyzes: for the outcome “ability to manage overall life circumstances,” the category BMI and sedentary time were statistically significant but had one category with a frequency of n < 5, respectively, and for the outcome EQVAS, the category EQVAS at the baseline had one category with a frequency of n < 5. Consequently, these three results were not regarded as statistically significant and thus not used in the multivariate modelling.Three potentially predictive baseline variables in the univariate analyzes had a category with a frequency of The main findings of the present study were that patients rating mild pain at the baseline were more likely to improve in “ability to manage overall life circumstances” as compared to those who rated moderate or severe pain. Further, patients reporting the shortest pain duration were more likely to improve in overall health as compared to those with the longest pain duration. Patients reporting anxiety/depression and patients rating severe pain at the baseline were more likely to improve in overall health status as compared to those with better baseline presentations. Finally, patients diagnosed with localized pain as opposed to regional/generalized pain at the baseline were more likely to rate reduced pain after the rehabilitation program PT-PRP. Our results suggest that for a successful outcome of this and similar kinds of rehabilitation, the patients should probably be offered this rehabilitation at an early stage to lower the risk of prolonged pain and consequently the risk of widespread pain development. Also, the results suggest that patients reporting anxiety/depression and severe pain at the baseline can still improve overall health after this kind of individual, physiotherapist-led rehabilitation of median 9 sessions. The question posed in the title could be replied in the affirmative. But, the results showed no strong and consistent predictive baseline variable, as for example a statistically significant baseline variable for all three outcomes. Therefore, the results found here can contribute to the clinical reasoning that still must be relied on in the clinic when deciding type of rehabilitation for patients with chronic musculoskeletal pain.To the best of our knowledge, there are no studies on predictive factors in accordance with the ones presented here regarding a patient population with chronic, severe pain who has completed a similar one-to-one, physiotherapist-led rehabilitation program. Various patient-populations with various severeness of symptoms have been studied, various content of rehabilitation programs have been used, and the studies have been performed in various health care settings in specialized and in primary care , 40–51. The results of the present study, namely, that no consistent predictive baseline variables can predict successful outcome are, however, supported by studies of multidisciplinary or interdisciplinary pain rehabilitation programs , 46, 47.Results of the present study and of previous research show that worse baseline status can be statistically significantly associated with improvements in outcomes after rehabilitation , 46–48. In a recent systematic review and meta-analysis of 9436 participants, Tseli et al. investigated “prognostic factors for physical functioning” 6 months after multidisciplinary rehabilitation . The autLocalized pain—as opposed to regional/generalized pain—was in the present study associated with clinically important improvements in pain intensity after rehabilitation. Gerdle et al. found in a registry study of 14,666 participants that widespread pain was associated with longer pain duration and more severe clinical presentations at the baseline but also with a poorer overall treatment outcome after interdisciplinary pain rehabilitation. Therefore, they suggested early interventions for this patient group . LikewisSome similar individual rehabilitation programs to the one used in the present study have been described previously. For instance, Wippert et al. used graded sensorimotor exercises and behavioral training combined rendering favorable results and recommended that exercise therapy should be individualized as far as possible . Also, GOne limitation of the present study concerns that anxiety/depression was estimated by only one question, although this was from a validated questionnaire (EQ5D). Even if this cannot be compared to more sophisticated instruments, such as hospital anxiety and depression scale (HAD) , our resAnother potential limitation is that not all eligible patients could be included in the final study cohort. Some patients in our clinic developed other diseases and needed other types of care, such as surgical interventions. Yet, the main reasons for not including patients in the final cohort were administrative. For example, administrative routines regarding questionnaires changed and questionnaires were exchanged during the five-year period due to developments in clinical work or regulatory changes in care that the unit had to follow. We believe that this is how everyday care works, and importantly, this has not affected our patient composition in the final cohort in any systematic way. For example, when questionnaires have been changed, it has not affected some selected patients but all patients. So, motivational and similar factors were only to a lesser extent reasons for not being included in the final cohort. In fact, only 41 patients (8%) chose to discontinue the program. We did not have access to baseline data for these patients and could therefore not perform a dropout analysis.n < 5 for any category should be deleted. Still, only three statistically significant potentially predictive variables had a category with a frequency of n < 5 in the univariate analyzes and were thus not used in the multivariate analyzes. Therefore, we do not believe that this had any major impact on our main conclusions.Further, the sample can be considered small when the variables were divided into 2–4 categories for each outcome (successful and unsuccessful outcome) in the regression analysis. This led us to collapse categories before starting the regression analysis since we decided in advance, that any variable with a frequency of We had no access to information on the patients' employment or working status–factors shown to be important in chronic pain , 63. HowIn conclusion, of 17 potentially predictive baseline variables, mild pain ratings, short pain duration, and localized baseline pain were statistically significantly associated with improvements after individual, physiotherapist-led rehabilitation for patients with CMP. This suggests that this type of pain rehabilitation probably should be offered early. Reporting anxiety/depression or severe pain at the baseline did not hinder the improvements of overall health.


Pain is usually subjective and thus it is challenging to describe its characteristics such as nature, intensity, and origin. Non-invasive methods such as assessing salivary alpha-amylase (SAA) may aid the practitioner to evaluate the pain intensity. Hence, the current study aimed to correlate the levels of SAA with the pain intensity in patients presenting with varied endodontic pain levels.Sixty patients who presented with varied intensities of endodontic pain were selected for the present study out of which seven patients were excluded/dropped, leaving a total sample of fifty-five patients for assessment. Mandibular molar with symptomatic irreversible pulpitis without periapical pathology were included in the study. A 5ml of un-stimulated was obtained from the patients, following which the local anesthesia was administered. Root canal treatment was then performed and the pain scores at pre-operative and post-operative were recorded. Additionally, salivary samples were collected after emergency endodontic treatment and sent for sialochemical analysis. IBM.SPSS statistics software 23.0 was employed to assess the obtained data.A statistically significant drop in the pain score (P < 0.001) and SAA levels (P < 0.001) were observed post-operatively in the contract to pre-operative state. A strong positive correlation was reported between SAA levels and pain scores in patients undergoing emergency endodontic treatment at both time intervals namely pre-operative (P < 0.001) and post-operative (P < 0.001).The results of this preliminary showed a strong association between the pain score and SAA levels in patients undergoing an emergency endodontic treatment. Pain is an unpleasant sensation which is most often related to potential injuries, due to psychosocial issues, or direct from other areas . Most ofThe pulpal and periapical pain is majorly stimulated by various physical and physiological factors, leading to nerve sensitization leading to a painful response . VariousPain is a complicated mechanism, which is difficult to understand. It’s highly subjective and varies from patient to patient. Multiple patient-based, and operator-based factors play a vital role in perceiving pain. The real pain can never be quantified. The patient’s threshold to perceive real-time pain varies based on both physiological and various psychological factors too . The dayPain is usually subjective, and it is challenging to describe its nature, intensity and identify the origin of pain. The use of non-invasive techniques, such as measuring salivary alpha-amylase, may assist the physician in determining pain severity . Saliva Amylase is an important enzyme and activates by the sympathetic reactions to psychosocial stress , 28. ThePain activates the sympathoadrenal medullary (SAM) activity and the hypothalamic-pituitary-adrenal axis. Exaggerated levels of the salivary alpha-amylase are seen in psychosocial stress, which indirectly reflects the SAM activity. As painful stimuli activate the SAM system and hypothalamic-pituitary-adrenal axis, pain-associated stress is related to salivary alpha-amylase levels , 29, 30.With norepinephrine, the parotid and submandibular glands’ acinar cells secrete more SAA . The levSalivary amylase levels were significantly associated with experiencing chronic pain, according to Shirasaki et al., 2004 . Pain scHence, the present study aimed to determine the association between salivary alpha-amylase and the intensity of pain. The previous investigation examined the relationship between salivary alpha-amylase levels and pain in patients who reported symptomatic irreversible pulpitis . This reThe institutional ethical committee had approved the protocol for the present prospective study . The current study has been registered on clinical trials.gov with the registration number REF/2023/06/068283. A total of 60 systemically healthy ASA I  individuals aged 18–55 years who presented varied pain intensities were selected for the study. Three patients were excluded before obtaining the salivary samples, as two of them took a rescue drug, and one had insufficient saliva. An additional two patients were lost during follow-up visits, with a remaining sample of 55 patients considered for the study , with an effect size of 0.5, α of 0.05 and CI of 95%. The total sample estimated was 54. The overall sample was adjusted to 60 to compensate for the loss of follow-up and other unexpected situations.Patients with mandibular molar presenting with symptomatic irreversible pulpitis were only selected. The tooth in question satisfied the criteria for the diagnosis of symptomatic irreversible pulpitis. The clinical diagnosis was determined based on prolonged symptomatic response to cold and electric stimuli with no tenderness on vertical or lateral percussion. The radiographic diagnosis of an intact lamina dura with no evident periapical widening associated with root apex was confirmative. After the preoperative diagnosis and selection of included subjects for participation in the present study, informed consent is obtained from the patients before allocation. Once the diagnosis was confirmed, each included patient was assessed for an initial baseline pain score using a visual analogue scale. Examiner 1 (K.V.T.) who obtained informed consent from the patient performed the clinical examination and wrote the diagnosis of the endodontic condition. In the interview section, the examiner recorded the details about the history of the pain including the patient’s previous treatments. He also charted the characteristics of pain including onset, type, nature, site, source, and aggravating and reliving factors. Before the anesthetic administration, a visual analogue scale (VAS) was used to measure the intensity of the pain and scores were recorded. A 5ml of unstimulated saliva was obtained from the patient in a plastic container with graded markings on it. The patient was instructed to sit upright with the neck bent forward, and the unstimulated saliva was collected using the spitting method , 38.Once the diagnosis was confirmed and VAS scoring was obtained, the patients were then randomly allocated into two groups by a head nurse using the opaque sealed envelope method. The patient and the operator were blinded by the pre-operative VAS scores.Once examiner 1 (K.V.T.) collected the pre-operative sample, the local anesthesia was administered by a blinded operator (S.R.). The entire treatment procedure was performed by a single operator (S.R.) blinded to the pre-operative data. Once the subject allocation was done, each subject was anesthetised by the standardised inferior alveolar nerve block, using 1.8ml of 2% lidocaine with 1:200.000 epinephrine and an additional second dose is administered if no profound anesthesia was obtained. Before injection, sterile gauze was used to dry the site of injection. Topical anestheic 20% benzocaine was applied using a sterile cotton applicator tip. Once the negative aspiration was performed, the solution was deposited at a rate of 1ml/min using a 27-gauge long needle. After 15 min waiting period, the patient was assessed for profound lip numbness. Once the lip numbness was confirmed, the rubber dam isolation was done and treatment was initiated. Patients, who experienced a failure of anesthesia, were administered supplemental infiltrations and intraligamentary injections. Intrapulpal anesthesia was a final resort in patients who experienced intolerable pain during pulp extirpation or instrumentation.As mentioned, after the confirmation of profound anesthesia, the rubber dam isolation was carried out and the standardized access cavity was prepared under an operating microscope (CARL ZEISS). Once the apical patency was maintained, the working was assessed using an apex locator. The working length radiograph was taken as a confirmative. Once the working length was established, the treatment protocol was initiated. Standardized instrumentation was carried out by hybrid technique using hand K-files and Protaper gold rotary files . Apical preparation was established to at least three sizes greater than the initial apical binding file. In due course of instrumentation, intermittent irrigation was carried out using 5% sodium hypochlorite (NaOCl)  with a 30-gauge side vented needle . 10ml of 5%NaOCl was used for each canal. The needle was oscillated at a frequency of 1 Hz, at an amplitude of 3 mm continuously until the end of the irrigant delivery. After the complete instrumentation, irrigation was carried out using 4ml of 5% NaOCL and 5ml of 17% ethylene diamine tetra acetic acid (EDTA), . The final rinse was carried out using 5 ml of distilled water. The entire syringe needle irrigation was carried out using a 30-gauge side vented needle attached to a 5ml syringe barrel. At the end of instrumentation and manual irrigation, activation was carried out using passive ultrasonic irrigant activation (PUI). An amount of 1 mL of 5.25% NaOCl was activated for 20 s, which was performed for 3 consecutive cycles using an IRRI S ultrasonic tip (VDW), attached to an ultrasonic device , at a power setting at 30, placed 1 mm short of the working length. Following the activation, the final rinse was carried out using 4 mL of 5.25% NaOCl, 5 mL of 17% EDTA, and 5 ml of distilled water.Canals were dried, the sterile cotton pellet was placed, and the closed dressing was given using resin-modified glass ionomer cement RMGIC . No intracanal medicament was placed, and the obturation was carried out on the next visit. Patients were requested to wait at the reception and were asked to report back to the operatory after 3 h. In the meantime, they were monitored in the outpatient department and not asked to take anything per oral. A resident doctor (who is not a part of the study and not aware of the pre-operative VAS scoring) was instructed to prescribe 600 mg of paracetamol as a rescue drug and patients were told to report if they had intolerable pain. Patients with unbearable pain and who have consumed the rescue drugs were excluded from the present study.After 3 h post-operatively, the VAS scoring was again recorded by examiner 2 (K.J.). Later, the salivary samples were collected, and the patients were dispersed from the clinic. By having different examiners (K.V.T and K.J.) for recording VAS scores at different intervals namely pre-operative and post-operative, the methodology bias was eliminated. Additionally, the operator (S.R.) was also not informed about the VAS scores. Lastly, while recording the post-operative VAS score, the patients were not reminded about their pre-operative score. Hence, all efforts were made to maintain double blinding.The present study was conducted for 60 days in the Department of Conservative and Endodontics. The experimental protocol was such that only one patient was evaluated in a day to prevent the disparity in results. The treatments started on or before 10 AM. Patients were not included in the study if they reported in the morning after 10:30 AM. The research was scheduled for the next day if the patient reported late. The reason was to ensure that a sufficient postoperative time limit was available as none of the patients were allowed to take anything per oral during the postoperative monitoring. The evidence from the literature shows that there is no role of the circadian rhythm, daily variation in a week, or gender difference in SAA levels under resting conditions . Hence, The samples were immediately transferred for sialochemical analysis. To obtain pure saliva, the samples were centrifuged for 3–5 min using . The SAA level was assessed using a biochemical kit  and a spectrometer  at a wavelength of 590 nm  and reduction in the salivary alpha-amylase levels (P < 0.001) was observed post-operatively when compared with pre-operative status (Table P < 0.001) in pre- and post-operative state, which was statistically significant  with the pain scores compared. Previous endodontic literature on evaluating these innate biological markers is scarce. According to our knowledge, there was only one study by Ahmadi et al., that proEndodontists are primary care providers before interventional specialists. So, as a primary care provider, the major responsibility is to provide pain-free treatment, especially in patients undergoing emergency endodontic therapy. Hence, it’s appropriate for a primary care provider to assess and evaluate the new avenues of biomarkers and their clinical applicability in therapeutic endodontics.None of the studies to date, in endodontic literature, have evaluated the present-mentioned protocol. Especially when consideration has to be given, there is scarce knowledge on the evaluation of patients’ pre and postoperative pain levels. In a clinical scenario, we usually tend to prescribe analgesics routinely and collect the postoperative pain scores after the treatment procedures. This is the routine protocol being followed for decades, to quantitatively assess the patient’s pain scores. Which may not be a replicate of a true condition and it’s more subjective than an objective correlation.Hence, the present study laid a unique perspective in the endodontic field, to assess the pain by clinically correlating the subjective pain scores with an innate biomarker evaluated. When the results of the present study are critically appraised, there was no gender-related bias or preoperative data-related bias. The reason for selecting the patients with mandibular molars, especially with baseline pain scores was because the reported postoperative pain score is more in patients who present with preoperative pain. This could be because of the activation of nociceptors, which leads to central sensitization . Hence, When the specific biomarker evaluation is compared, many studies in pediatric literature have evaluated the correlation of the SAA levels with innate correlates such as heart rate and blood pressure in children undergoing dental treatment, to evaluate the anxiety levels –78. The When consideration has to be given to other specific biomarkers in dentistry, literature is sparse on especially substance P, which is a true positive correlate to pulpal pain. To our knowledge, only one clinical study by Ahmad et al., found a positive correlation and increased salivary substance P concentrations in patients presented with dental pain . But theWhen the standardization of the study is analyzed, the teeth selection and the specific preoperative condition were similar for all the patients included in the study. To exclude other possible reasons which might interfere with the inference of the study measures were taken to select the patients with higher baseline pain scores, patients were selected such that they did not consume any prior analgesic before the intervention, patients with additional teeth presenting with pulpal and periapical pathosis, patients under any medication or analgesic intake for pain management or any other medical condition, patients with multiple teeth requiring endodontic treatment were excluded. Only patients categorized under ASA I was only selected for the present study.The reason for mandibular molars and especially with higher baseline pain scores for the present study was mainly because; the literature shows that, the reported postoperative pain was severe in these teeth . When seWhen the limitations of the present study are considered, the protocol might not be feasible in a true clinical scenario. The patients selected in the present study were only ASA I, patients. However, usually, the patients attending the dental clinic are systemically compromised most of the time. When consideration has to be given to preoperative analgesic intake, most of the patients consume one or the other analgesic before intervention. The sample size of the present study is insufficient to give generalized statements. Hence, future trials have to concentrate on increased sample size along with using additional biomarkers for evaluation.Current study revealed a positive association between SAA levels and pain scores in patients undergoing emergency endodontic treatment. Hence future studies should concentrate more on this biological marker to assess its role in endodontic pain.