Background. Little is known about the clinical impact of new root canal preparation systems in general dental practice under routine care conditions. Therefore, we compared hand instrumentation (H) with Reciproc (R)  preparation. The outcomes were endodontic related pain and oral health related quality of life (OHRQoL), evaluation of the procedures by the patients and the strain felt by the dentists during root canal therapy.Methods. Six dentists participated in the trial as practitioner–investigators. In the first phase of the trial they prepared root canals with H and in the second phase with R. The patients documented their pain felt with a visual analogue scale (VAS 100) and OHRQoL with the German short version of the oral health impact profile (OHIP-G-14) before treatment and before the completion of therapy and answered questions about how they experienced the treatment. The dentists documented their physical strain during treatment.Results. A total of 137 patients were included in the evaluation. 66 patients were treated with H, 71 with R. Pain reduction was 32.6 (SD 32.9) VAS (H) vs. 29.4 (SD 26.9) VAS (R) (p = 0.550), and the improvement of the OHIP-14 score was 5.5 (SD 9.2) (H) vs. 6.7 (SD 7.4) (R) (p = 0.383). There were no statistical differences in both groups. Significantly fewer patients felt stressed by the duration of treatment with R as with H (p = 0.018). Significantly more dentists reported that their general physical strain and the strain on their fingers were less severe with R than with H (p = 0.013 and p < 0.001).Discussion. H as well as R effectively reduced endodontic related pain and OHRQoL without statistical differences. R has advantages in terms of how patients experience the treatment and regarding the physical strain felt by the dentists. There is a wide selection of instruments for root canal preparation , 2011. WIn vitro studies prove that mechanical root canal preparation systems are superior to hand instrumentation in relation to various parameters, such as root canal straightening, preparation faults and preparation time  is a common and effective treatment for the relief of endodontic-related pain , 2011. WThis is why research is needed in the field of new endodontic instruments. For the purpose of such research, we formed a network of several dental practices and performed a multicenter trial , 2011. FThe following two-sided hypotheses were investigated in the study:Does root canal preparation using Reciproc lead to more or less reduction of patients’ endodontic related pain and oral health related quality of life (OHRQoL) compared to using hand instruments?Do patients feel the Reciproc preparation to be more or less comfortable compared to hand instrumentation?Can more root canals be prepared without glidepath preparation with Reciproc compared to hand instrumentation?Is the physical strain on the GDP during root canal preparation with Reciproc lower compared to hand instruments?We conducted the present study as a clinical multicenter trial under routine care conditions. The study involved nine dentists as practitioner investigators (PIs). They recruited a sample of consecutive patients who needed a root canal treatment. The two phases of the study were separated by the training period for the new treatment method. The authors of this study did not act as PIs, but solely as investigators.In the first study phase endodontic therapy was performed in the usual way with hand instruments. The PIs consecutively included all patients in the study who required endodontic therapy. Then the PIs were trained for the use of the Reciproc System . The one-day training course explained the theoretical bases of the Reciproc System  for root canal preparation and included hands-on training on extracted teeth. At the end of the training course every participating dentist was technically able to prepare root canals by the new method in a reliable way. The training period was short on purpose because we wanted to simulate a common situation of changing treatment methods in general dental practice regarding the timeline sequence.In this way we calibrated the investigators and reduced the organizational demands on the dental offices, because they did not have to perform two different methods of treatment at the same time.In the second phase of the study the PIs treated their patients with the Reciproc instruments (R) exclusively. Each of the two treatment phases lasted for 2–3 months.The study was made in conformity with the Declaration of Helsinki and the Professional Code for Physicians of the Medical Council of the State of Baden-Württemberg. The PIs informed every potential participant personally about the purpose and extent of the study and about the data protection aspects . Before the patients were enrolled, they had to submit signed informed consent to the study and to data storage. The Institutional Review Board of the Baden-Württemberg Medical Council reviewed the study and approved it (AZ: F-2011-081-z).The structural similarity of the patients in the two phases was enhanced by inclusion and exclusion criteria. The following criteria were defined for patients’ enrollment in the study: the patient had to be at least 18 years old and in need of initial orthograde root canal treatment of one tooth. The exclusion criteria were: hopeless teeth for periodontal or restorative reasons, patients treated for pain only, dentitions in general need of rehabilitation, several symptomatic teeth requiring endodontic treatment, other oral findings causing pain, craniomandibular dysfunction, and communication difficulties.The nine recruited dentists were general dental practitioners without endodontic specialization. They all used standard hand instruments for root canal therapy (RCT) and had no routine experience with rotary mechanical instrument systems. In addition, none of them had previously used single-file systems. All dentists followed the “Good Clinical Practice: Root Canal Treatment” Guideline of DGZMK  , 2005 whThe endodontic access cavity was prepared under local anesthesia. Then the tooth was isolated with a rubberdam. In the first phase of the study, depending on the situation, the root canals were explored with stainless steel K-files of ISO sizes 06, 08, 10 and 15, in order to create a glidepath up to ISO 15. Subsequently the root canals were fully prepared with stainless steel K-files by the balanced-force technique when hand instrumentation was used , 1985. TThe endodontic related pain and OHRQoL was measured by a patient questionnaire. Pain was evaluated by the Visual Analog Scale (VAS 100) , 2011 anAt completion of treatment the PI asked four closed questions in a five-stage ordinal scale and one open question about how the patients had experienced the treatment. They asked if the patient was stressed/relaxed during treatment, if the anesthesia was sufficiently deep, if the duration of treatment and the required wide mouth opening had put the patient under stress. The answers covered five categories from completely true to not true at all. One open question was about the most uncomfortable experience patients had during treatment.In order to evaluate the physical strain during root canal preparation, the PIs answered two closed questions in a five-stage ordinal scale from “completely true” to “not true at all” after treatment. The PIs were asked if their general physical strain during root canal treatment was high and if after treatment they experienced the strain on their fingers. In addition, they were asked if the treatment was performed without glidepath preparation. The number of required therapy appointments was also recorded.The data were analyzed with the SPSS  statistics system.Six of the nine recruited PIs presented results suitable for evaluation. The remaining three PIs were excluded from evaluation. In all three cases the PIs could not cope with the organizational demands and the resulting recruitment problems.p = 0.301). The PIs treated between 5 and 20 cases per study group . The average age of the participants was 52.1 (SD 16.33) years and did not differ in both study phases 52.1 (SD 16.4) vs. 52.0 (SD 16.4).In the present study six PIs performed and completed 137 endodontic treatments . The PIsdy group . The disThe return rate of the different questionnaires that were completed by the patients and the PIs was 95.8% for the patients’ follow-up pain questionnaire and 100% for the PIs’ questionnaires. The return rate of the patients’ pain questionnaire before treatment was 97.8% and for the demographic data questionnaire it was 98.5%. In all dental practices some patients did not participate in the study. Their number and characteristics could not be collected. However, it is unlikely that this drop-out in the two study phases was structurally different.For the evaluation of the primary outcome criterion, we measured pain reduction by VAS (100) and the improvement of OHRQoL (OHIP-G14 score), each being measured before root canal treatment and before completion of treatment, and compared the two study groups .The mean pain score before root canal treatment with hand instruments (H) was 43.6 (SD 30.7) VAS and with Reciproc (R) it was 41.2 (SD 27.7) VAS and decreased to 9.5 (SD 16.5) VAS (H) and 11.5 (SD 18.5) VAS (R).The mean OHIP-G-14 score before root canal treatment with (H) was 9.2 (SD 9.6) and with (R) it was 10.4 (SD 9.6) and decreased to 3.4 (SD 5.4) (H) and 3.5 (SD 6.1) (R).p > 0.250).For pain reduction and OHRQoL univariate analysis methods (ANOVA) showed a very similar improvement in both study groups H and R . The difU Test p = 0.018).Most patients did not experience the root canal therapy as uncomfortable, regardless of the method used. Most patients were rather relaxed during treatment, considered the depth of anesthesia to be adequate and felt no great stress due to wide mouth opening . The twoThe most frequent answer to the open question of what patients felt to be most uncomfortable during treatment was “nothing” in both study groups. In the ranking of answers given, more patients said that the root canal preparation itself was more uncomfortable with Reciproc, whereas few patients said this about hand instrumentation. In addition, some patients considered the rubber dam uncomfortable .U Test p = 0.013 and p < 0.001)  .χ2 27.7 with 1 DF, p < 0.001).Moreover, the PIs treated significantly more root canals without glidepath preparation when they used the Reciproc System (67.6%) than they did with hand instruments (22.7%) (U Test p = 0.035). With hand instrumentation 34 cases were completely prepared in one appointment, 12 in two appointments and 1 in three appointments, whereas with Reciproc 42 cases were prepared in one appointment, 5 in two and none in three appointments.Basically the number of therapeutic appointments did not differ between the systems. Two PIs, however, treated their patients in three appointments as a matter of principle. If these are excluded from the evaluation, the number of appointments tends to decline with Reciproc  and 41.2 (R) VAS 100 to 9.5 (H) and 11.5 (R) with rather high standard deviations. This agrees quite well with other studies that reported pain reduction after endodontic therapy , 2012. TThe oral-health-related quality of life improved in our trial from mean OHIP-G-14-scores of 9.2 (H) and 10.4 (R) to 3.4 (H) and 3.5 (R). In general, the endodontic literature proves that pain is reduced by endodontic therapy , 2011. HN = 30 per experimental group), that have investigated pain after root canal preparation with different instrumentation techniques  have to be considered regarding their influence on post treatment pain. All endodontic instruments produce apically extruded debris , 1998 thin vitro comparisons with multiple-file rotary preparation systems . In our trial the number of appointments required for root canal treatment tended to go down. As far as the authors know, no study has so far been made on the influence of the preparation methods on the number of therapeutic appointments. In general, the treatment result hardly shows whether an endodontic therapy was performed as single-visit or multiple-visit procedure , 2011. AHand instrumentation and Reciproc preparation effectively reduce endodontic related discomfort. Reciproc, however, has advantages in terms of how the patients feel during treatment and with regard to the physical strain on the dentist. For the patients the duration of treatment with Reciproc is less stressful and the number of appointments tends to be lower. The dentists consider Reciproc to be significantly less physically stressful than hand instrumentation.10.7717/peerj.2182/supp-1Data S1Click here for additional data file.


Oral mucositis (OM) is among the most undesirable, painful, and expensive toxicities of cytotoxic cancer therapy, and is disheartening for patients and frustrating for caregivers. Accurate assessment of the incidence of OM has been elusive, but accumulating data suggests that reported OM frequency is significantly less than its actual occurrence. It has been suggested that over 90% of head and neck cancer (HNC) patients receiving radiotherapy (RT) with concurrent cisplatin experience severe OM with symptoms of extreme pain, mucosal ulceration and consequent limitations in swallowing and achieving adequate nutritional intake. This panoply of symptoms inevitably impacts a patients’ quality of life and their willingness to continue treatment. In spite of all the advances made in understanding the pathophysiology of OM, there is still no prophylactic therapy with proven efficacy. Strategies to limit the extent of OM and to manage its symptomatology include basic oral care, supportive medications, nutritional support and targeting aggressive treatments to high-risk patients. This review focuses on OM recognition, preventive measurements, and symptom-management strategies. The prerated RT . With thrated RT .The relevance of OM extends from patient-related quality of life issues to provider-related concerns for timely treatment delivery and symptom minimization and finally, to broader health-system implications including costs inherent in the treatment of OM. For example, severe OM delays the subsequent chemotherapy cycle in 35% of patients; in 60% of patients, grade 3–4 mucositis causes dose-reduction and in an additional 30% of patients, chemotherapy is discontinued altogether . These cThe severity of OM ranges from superficial erythema with accompanying soreness, to full-thickness mucosal ulcerations and significant pain. These signs and symptoms are thought to correlate with the high levels of pro-inflammatory cytokines released during the development of OM ,14. AmonIt is clear then, that the clinical impact of OM is profound. Even when described as mild to moderate, OM is still associated with increased oral pain, weight loss, dietary modifications (including gastrostomy tube placement and subsequent use), dehydration, and reduced performance status ; even miOM is associated with a wide range of symptoms, a diminished quality of life (QOL)  and signIt is critically important to develop and validate methods that can quantify the degree of OM experienced by patients. This will allow the formulation of targeted interventions that efficiently combat this adverse chemotherapy-related outcome. The Multinational Association of Supportive Care in Cancer and the International Society for Oral Oncology (MASCC/ISOO) proposed that an OM assessment tool should be objective, sensitive, validated, reliable and easy to use in all clinical applications. An emerging body of evidence suggests that assessments of OM should include a standardized instrument or combination of instruments measuring not only physical and functional factors, but also patient-perceptions ,22. The i.e., “magic mouthwash”, chlorhexidine oral rinse) are available over the counter, used off-label or marketed as devices, the U.S. Food and Drug Administration (FDA) has approved none of these interventions for the prevention of OM. The MASCC/ISOO recently updated its clinical practice guidelines for mucositis prevention [A number of diverse interventions have been tested for the prevention of mucositis in HNC patients receiving CRT. Although many of these interventions  is the only agent approved by the U.S. FDA and the European Medicines Agency (EMA) for OM. This approval was based on a body of evidence that included a large, well-designed, randomized controlled trial as well as other supporting studies recommending the use of palifermin to prevent OM in patients diagnosed with a hematologic malignancy planned for high-dose chemotherapy, total body irradiation followed by autologous stem cell transplantation . In the Another potential agent considered in the prevention of OM is that of the granulocyte-macrophage–colony-stimulating factor (GM–CSF). A review of the evidence not only suggests against the use of granulocyte-macrophage–colony-stimulating factor mouthwash, but it also finds reduced local tumor control when used during HNC RT. In a randomized, multicentric trial evaluating the preventive effect of granulocyte colony-stimulating factor (G-CSF) in patients receiving hyperfractionated RT or concomitant CRT, there was an unexpected increase in locoregional failures experienced by patients with stage III–IV squamous cell carcinoma of the head and neck area .p = 0.037). Patients receiving benzydamine rinses experienced a significant delay in the need for opioid analgesia as compared to the group on placebo drug (p < 0.05) [p = 0.001) [Benzydamine hydrochloride is a nonsteroidal anti-inflammatory drug that can inhibit the production of proinflammatory cytokines such as tumor necrosis factor-α and interleukin-1b. The MASCC/ISOO mucositis guidelines recommends the use of benzydamine mouthwash to prevent OM in patients with HNC who are receiving moderate-dose RT (up to 50 Gys) without concomitant chemotherapy. In the initial study, prophylactic use of benzydamine was assessed with patients undergoing a weekly clinical evaluation before, during and up to a maximum of 3 weeks following the completion of treatment. The benzydamine group demonstrated a 30% reduction in the incidence of erythema and radiation-induced ulcers. In addition, 33% of patients who received the study drug did not show any signs of radiation-induced ulceration as compared to 18% of patients who received placebo ( < 0.05) . It is i < 0.05) . In a se= 0.001)  of sever= 0.001) ,32.2/spot size 4 mm2; Group 2 LLLT dose: 660 nm/5 mW/1.3 J/cm2/spot size 4 mm2), patients randomized to the high-dose LLLT (group 1) had less severe OM and reduced pain during RT [Low-level laser therapy (LLLT) is a local application of a monochromatic, narrow-band, coherent light source. The MASCC/ISOO guidelines suggest that low-level laser therapy (wavelength around 632.8 nm) can be used to prevent oral mucositis in patients undergoing radiotherapy, without concomitant chemotherapy, for head and neck cancer (Level of evidence III).  The mechuring RT . It is iuring RT ; howeverOM pain is reported in the majority of HNC patients undergoing treatment . It inteMorphine is the classic example of an opioid used for its analgesic effects. These effects result from its capacity to bind to opioid receptors in the central nervous system as well as those in the periphery. Basic science research suggests that morphine provides analgesic relief when locally applied to tissues damaged from a series of inflammatory events ,43,44; tMuch of the evidence used to manage OM-associated pain is extrapolated from the bone marrow transplant literature. Another well-described systemic opioid with marked efficacy in this setting is fentanyl, a short-acting synthetic opioid with potent analgesic capabilities that can be administered intravenously or subcutaneously. The low molecular weight, high potency, and high lipid solubility of fentanyl allows it to be delivered easily transdermally where a controlled-release membrane allows for a 72-hour reservoir to be steadily absorbed through the skin into the microcirculation and subsequently, systemically into the bloodstream. The variety of available transdermal dosages allows for easy titration, particularly in patients with compromised swallowing facilities. Two prospective trials have shown that the routine use of transdermal fentanyl reduced the intensity of pain and improved the quality of life of patients suffering from severe OM ,51.Breakthrough pain is a common occurrence in HNC patients, particularly during swallowing, coughing (expulsion of mucus) and at otherwise unforeseen moments. Difficulties in swallowing can limit the efficacy of traditional pills; PEG-tubes, while offering a secondary route for medication delivery, are compromised in that they cannot often accommodate opioid tablet sizes. Crushing opioids usually impacts the efficacy of the drug. At present, breakthrough pain has relied on liquid formulations of opioids—a delivery mechanism that can accommodate patients with a degree of swallowing ability as well as those with PEG tubes.Innovation around pain management has focused predominantly on mechanisms of prognosticating mucositis severity in the HNC patient initiating therapy. While still in early phase development in HNC patients, the technique of modeling symptom clusters through the combined use of computational biology technologies with molecular, clinical and genetic tissue markers is a means of risk stratifying mucositis severity. This, in turn, will help early and effective identification of patients at risk .versus tricyclic antidepressants for OM-associated pain in HNC receiving RT, up to 40% of patients achieved sufficient pain control on tricyclic antidepressants alone [In patients with OM-associated neuropathic pain or a mixed pain picture, there is a definite role for adjuvant therapies . Two retts alone . AlthougDoxepin hydrochloride is a tricyclic antidepressant that has demonstrated anesthetic and analgesic properties with topical administration. In a recent randomized trial organized by the Alliance Cooperative Group, oral rinses with Doxepin diminished the intensity of OM-associated pain as compared to placebo. However, no reduction in the opioid dosing was observed in this study . This suversus NGT feeding [The maintenance of adequate nutritional support is imperative in patients with malignancies of the upper aero-digestive tract for whom the goal is definitive CRT with curative intent. Without these supportive measures, the data evidences an increased risk of treatment interruptions resulting in a reduction in tumor control and overall survival . Two pri feeding ,62 has i feeding .Poor nutritional status also translates to potential electrolyte abnormalities. A review of lab values in patients undergoing concomitant CRT not maintaining adequate nutritional support, suggests a significant relationship between creatinine percent or BUN rise, and percent body weight loss. Dehydration associated with severe dysphagia during CRT and an inability to feel thirst is the likely causative actor . In our Re-feeding syndrome is an under-recognized side effect of CRT treatments. Usually defined as a potentially fatal syndrome in which dangerous fluid and electrolyte shifts occur in malnourished patients undergoing artificial re-feeding by enteral or parenteral routes, it is a complex syndrome with hypophosphatemia as the hallmark feature. Other electrolyte imbalances that can occur include changes in glucose, protein and fat metabolism, abnormalities in sodium and fluid balance as well as thiamine deficiency, hypokalemia and hypomagnesemia . The mai2 or negligible intake for 2 weeks or more), the NICE guidelines recommend re-feeding start at a maximum of 5 kcal/kg/24 h in combination with cardiac monitoring, due to the risk of cardiac arrhythmias [To effectively prevent re-feeding syndrome, a thorough nutritional assessment needs to be carried out before re-feeding is initiated. Important factors to assess include weight loss over time, current nutrition, existing social issues including alcohol intake, and any underlying psychological issues. Baseline plasma electrolytes, especially phosphate, sodium, potassium and magnesium, and glucose should be measured before feeding and closely monitored and corrected during re-feeding. For patients at high risk of developing re-feeding syndrome, repletion of calories should be started slowly  with a planned slow increase to meet individual patient needs over 4–7 days. In patients who are very malnourished (e.g., BMI less than 14 kg/mhythmias . In genehythmias . Potassihythmias .In summary, re-feeding syndrome, while easy to prevent and detect, is often overlooked. Patients with HNC are a patient population with multiple risk factors for nutritional depletion including malignancy-associated cachexia, dysphagia and odynophagia, iatrogenic treatment effects and pre-existing detrimental social behaviors and therefore, are at increased risk of re-feeding syndrome.As our understanding of the pathophysiology of OM begins to include underlying molecular mechanisms, new potential targets for therapeutic interventions will be identified. To date, different topical and systemic medications are being used, yet no single efficacious intervention or prophylactic agent has emerged as the leading treatment in the management of CRT-induced OM. Although several ongoing clinical trials are looking into manipulating the inflammatory cascade associated with CRT-induced tissue damage, standard preventive techniques are still focused on adequate oral hygiene, pain management with topical and systemic analgesics and timely identification of symptomatic complaints that herald an infectious process. Supportive measures that address nutritional intake, electrolyte management, dehydration and aggressive pain management are still, the best means of preventing OM.


Rhinogenic contact point headache (RCPH) is a pain that arises from two opposing mucosal surfaces in the nose. The diagnosis is made by history and physical examination along with nasal endoscopy and imaging. The mainstay of treatment is surgical removal of contact area.To evaluate the effectiveness of non-surgical managements including behavioral and pharmacotherapy in treatment of RCPH.Thirty patients with confirmed diagnosis of RCPH underwent non-surgical management of RCPH using recommendations for absolute contralateral nostril breathing during the pain period, applying warm cushion and medical treatment with non-steroidal analgesics and beta blocker. The results of treatment compared with the results of a group of patients who underwent surgical management.More than eighty six percent of patients experienced a significant relief in the severity of the pain. In contrast to the surgically managed group, the frequency of headaches was not altered.Non-surgical management of RCPH may have a role in patients who do not accept surgery or are not a candidate for surgical management.No conflict of interest.


Objective: Many patients who attend an emergency department (ED) with chest pain receive a diagnosis of non-cardiac chest pain (NCCP), and often suffer poor psychological outcomes and continued pain. This study assessed the role of illness representations in explaining psychological distress and continued chest pain in patients attending an ED.Methods: ED NCCP patients (N = 138) completed measures assessing illness representations, anxiety, depression and quality of life (QoL) at baseline, and chest pain at one month.Results: Illness representations explained significant amounts of the variance in anxiety (Adj. R² = .38), depression (Adj. R² = .18) and mental QoL (Adj. R² = .36). A belief in psychological causes had the strongest associations with outcomes. At one month, 28.7% of participants reported experiencing frequent pain, 13.2% infrequent pain and 58.1% no pain. Anxiety, depression and poor QoL, but not illness representations, were associated with continued chest pain.Conclusions: The findings suggest that (i) continued chest pain is related to psychological distress and poor QoL, (ii) interventions should be aimed at reducing psychological distress and improving QoL and (iii) given the associations between perceived psychological causes and psychological distress/QoL, NCCP patients in the ED might benefit from psychological therapies to manage their chest pain. Acute chest pain accounts for approximately 700,000 emergency department (ED) attendances each year in England and Wales  who have been informed of their NCCP diagnosis, and then relate these perceptions to a range of measures of psychological distress and continued chest pain at one-month follow-up. In line with the CSM  questionnaire that was either completed in the clinic or returned in a freepost envelope. Participants were sent a follow-up questionnaire by post one month later. Participants who failed to return their questionnaires were contacted by phone after one week.The inclusion criteria for this study were based on a previous study in the same ED , cyclical timeline , consequences , treatment control , personal control , emotional representations , coherence , risk causes , psychological causes , immunity causes , chance causes , cardiac causes (1 item) and gastrointestinal causes (1 item). For the identity dimension, the number of symptoms (e.g. breathlessness and dizziness) that participants attribute to their chest pain is summed (min. 0 to max. 10). All other items are scored on five-point response scales and averaged to provide a score for each dimension. Higher scores indicate belief in a stronger identity, a longer timeline, worse consequences, more control, more coherence, more negative emotions and a stronger belief in the individual causes. Internal reliabilities for the subscales were all acceptable to high (Cronbach’s α’s > .70), except for the immunity causes (α = .62) and chance causes subscales (α = .24). As the Cronbach’s α for the chance subscale was particularly low, only the first item from this two-item subscale was used to assess chance causes (i.e. ‘Chance or bad luck’).Illness representations were assessed using the Illness Perceptions Questionnaire-Revised  and depression (α = .86) subscales were good.Anxiety and depression were assessed using the Hospital Anxiety and Depression Scale  or frequent pain (≥weekly) at follow-up.n = 1068), known CHD (n = 827), other life-threatening non-cardiac pathology (n = 135), unable to speak/read English (n = 51), and aged under 25 (n = 27), as well as unrecorded (n = 1689) reasons. A further 228 patients were not invited due to administrative reasons (e.g. staff were too busy). Overall, 489 patients were invited to participate in the study; 83 (17%) declined participation. Of the 406 patients who agreed to participate in the study, 392 opted to return the questionnaire via freepost envelope. Over the course of the study eight participants withdrew, one died and seven could not be contacted as they no longer lived at their contact address. Of the remaining 390 participants, 200 (51%) returned the initial baseline questionnaire, of whom 138 (69%) completed the second questionnaire. Details regarding the demographic profile of participants at time 1 and 2 can be found in Table During the study period, 4514 patients attended the ED with chest pain and were referred for cardiac investigation. Of these patients, 3797 met at least one of the exclusion criteria, including cardiac chest pain (t(197) = 3.46, p = .001, more likely to be female, x² = 7.42, p = .006, less anxious, t(195) = 2.47, p = .014, had lower perceptions of risk, t(182) = 3.23, p = .001 and psychological causes, t(182) = 2.36, p = .020, than non-responders.Participants who responded to the one-month follow-up questionnaire were significantly older, M = 4.7), t(135) = 5.64, p < .001; however, levels of depression were not, (M = 4.7), t(135) = 0.65, p = .52. Mental QoL was significantly poorer than in those with minor medical complaints , t(135) = 8.84, p < .001; however, physical QoL did not differ, (M = 47.42), t(135) = 0.28, p = .78. At one-month follow-up, 39 (28.3%) participants reported experiencing further frequent chest pain, 18 (13.0%) reported infrequent chest pain and 81 (58.7%) reported no further chest pain.Mean scores for all psychological and illness representation variables are reported in Table r(135) = −.23, p = .01, depression, r(135) = −.18, p = .04 and worse mental QoL, r(135) = −.20, p = .02; gender was not related to any of the psychological outcomes.Considering the IPQ-R dimensions, chronic timeline, consequences, emotional representations and perceived causes  were significantly correlated with anxiety, depression and mental QoL . As age correlated with most of the outcome variables, it was included as an independent variable, along with all illness representation variables. Beta values for each analysis are reported in Table R² = .38, F = 5.32, p < .001, 18% of the variance in depression, Adj. R² = .18, F = 2.58, p = .003 and 36% of the variance in mental QoL, Adj. R² = .36, F = 5.06, p < .001, but only 8% variance in physical QoL, Adj. R² = .08, F = 1.59, p = .09. A stronger belief in psychological causes was significantly associated with poorer outcomes in all the analyses , and a more chronic timeline was significantly associated with increased anxiety and depression and poorer physical QoL. A weaker belief in cardiac causes was associated with increased depression; however, the beta value was larger and in the opposite direction to the corresponding correlation coefficient, and is therefore likely be due to a suppressor effect.The variables included in the regression models explained 38% of the variance in anxiety, Adj. post hoc analyses to assess between group differences  at one-month follow-up, with subsequent Tukey n = 77, infrequent pain n = 18 and frequent pain n = 39). Two discriminant functions were calculated, which together significantly discriminated between the chest pain frequency groups, χ²(8) = 19.83, p < .001, although the second function alone was not significant, χ²(3) = 5.59, p = .13. As a result, only the first discriminant function is interpreted. The first function accounted for 11% of the total relationship between the predictors and group membership, Canonical R² = .11 and accounted for 72.5% of the between group variability. Examination of the combined plot of discriminant functions  by almost a third (31.2%) of participants. The next most frequently endorsed cause was chance (19.7%). All other causes were endorsed by less than 10% of the sample. These findings may, in part, be related to the timing of the baseline questionnaire, which was administered after patients received their NCCP diagnosis in an ED, which rules out a cardiac cause for the chest pain, but fails to provide a definitive alternative explanation. Gastrointestinal causes may be the next most obvious explanation, although they were unrelated to psychological distress, QoL or continued chest pain. Instead, participants who gave more weight to psychological causes had higher levels of psychological distress and poorer QoL, suggesting that some patients are aware of the potential link between anxiety and NCCP. Future research should seek to explore causal beliefs in patients with NCCP, using qualitative methodology, to examine this in detail.The perception of psychological causes and a chronic timeline were related to elevated levels of psychological distress and poorer QoL, which, in turn, were related to continued chest pain. This supports previous findings that illness representations are related to psychological morbidity  pain have been shown to report a more chronic timeline . This may therefore impact the findings, as it is possible that those who attend the ED outside of these hours may differ in terms of characteristics such as anxiety. However, patients who were discharged between 7 pm and 9 am were often asked to return to the ED during working hours for an exercise tolerance test, at which point they would have been screened for eligibility.The final caveat is that the sample was recruited from one ED in the UK, which may further limit the generalisability of the findings. However, the age and gender profile of the sample reflected those reported in previous studies of acute care NCCP patients  and Medical Research Council (UK) interdisciplinary studentship. There are no conflicts of interest.


Pain is a common symptom related to inflammatory bowel disease (IBD). In addition to abdominal pain, pain can also be an extraintestinal manifestation of IBD. Pain treatment is challenging and a substantial part of IBD patients are treated with opioids. Therefore, a better knowledge on pain symptoms is crucial for a better therapeutic approach to this clinical problem.Patients of the Swiss IBD Cohort Study (SIBDCS) (n = 2152) received a questionnaire regarding pain intensity, pain localization and impact of pain on daily life and social activities. Furthermore, the questionnaire investigated the use of pain-specific medication.A vast majority of patients (71%) experienced pain during the disease course. For a substantial part of patients (49% in UC and 55% in CD) pain is a longstanding problem (>5 years). Pain in UC was of shorter duration compared to CD (p < 0.01). Abdominal pain (59.5%) and back pain (38.3%) were the main pain localizations. 67% of patients took pain medication; 24% received no pain treatment. The general quality of life was significantly lower in patients suffering of pain compared to those without pain  p<0.0001).Prevalence of pain is high in patients of the SIBDCS. It is a longstanding problem for the majority of the patients affected. Pain was found to be undertreated in the SIBDCS and was significantly associated with health-related quality of life. Thus, an increased awareness is mandatory to address this frequent complication in the course of IBD. Abdominal pain is a common symptom related to Crohn’s disease (CD) and ulcerative colitis (UC), also collectively known as inflammatory bowel disease (IBD). During disease flares pain is present in 50–70% of IBD patients, 2. PainPronounced severe impact of pain on health related quality of life (HRQOL) is known for various diseases–20. LongIn a German study including some 300 patients using a specifically designed questionnaire regarding pain and HRQOL 87.9% of IBD patients reported pain and showed a significantly reduced HRQOL. Surgery reduced pain and patients on analgesics reported more pain and lower HRQOL than patients not on analgesics .Pain may directly be caused by inflammation as inflammatory cytokines and mediators have been shown to sensitize primary afferent neurons. But ongHere, we evaluated the well-characterized patient collective of the SIBDCS regarding pain, its impact of pain on daily life and social activities and the use of pain-specific medication. With 1’263 IBD patients included we present, to our best knowledge, the most extensive analysis of pain in IBD up to date.In the nationwide Swiss IBD Cohort Study (SIBDCS) patients with IBD from all regions of Switzerland have prospectively been included since 2006. In the SIBDCS at inclusion retrospective data is collected and afterwards patients are followed-up on a yearly basis. The cohort study is supported by the Swiss National Science Foundation and approved by the local ethical committees . As a participant of the SIBDCS the patients gave written informed consent for their clinical records to be used in this study. The cohort goals and methodology are described elsewhere.2152 adult patients of the SIBDCS received a questionnaire regarding pain localization, impact of pain on daily life, how the surrounding responds to the patients’ pain and how activities of daily life are influenced. Furthermore, the questionnaire investigated the use of pain-specific medication. To develop the questionnaire, we used the validated German pain questionnaire. Out of Clinical data were retrieved from the data center of the SIBDCS at the University of Lausanne. These data and additional data obtained from a review of the patients' files were entered into a database .A descriptive statistical analysis was performed. Categorical variables were summarized as frequencies and percentages, whereas quantitative variables as median and range. Differences in categorical data distribution between groups were assessed using the Chi-squared test, or the Fisher’s exact test in case of insufficient sample size. The general wellbeing was analyzed by student’s t-test. For the analysis of the disease duration the Wilcoxon-Mann-Whitney ranksum test was used. A p-value < 0.05 was considered statistically significant. All statistical analyses were carried out using GraphPad Prism 5.04 for Windows (GraphPad Software Inc.).We received 1263 completed questionnaires (response rate 59%). 599 from 1263 of the patients were male (47%) and 664 were female (53%). The median age was 47 years. 679 patients had the diagnosis of CD (54%), 556 UC (44%), 28 indeterminate colitis (IC) (2%). EIM of IBD were present in 699 patients (55%). The median disease duration was 15 years (0–57 years) . The meaA total of 1263 completed questionnaires was analyzed regarding pain. The vast majority of patients  reported having experienced pain in general during the course of the disease. Only 369 (29%) of the patients that sent back the questionnaire reported no pain . There wPain was a longstanding problem for the majority of the patients with 52% (469 patients) of patients experiencing pain >5 years. Fifteen patients (2%) reported pain since <1 month, 57 patients (6%) suffered from pain since 1 month—½ year, 59 patients (7%) since ½ year– 1 year, 79 patients (9%) since 1–2 years and 215 (24%) since 2–5 years . When coWhen characterizing the pain of all 894 IBD patients reporting of pain in general, 493 patients (55%) had pain attacks with no pain in between and 111 patients (12%) had pain attacks without being completely free of pain in between. 162 patients (18%) had a constant pain with slight fluctuations, 80 patients (9%) had constant pain with strong fluctuation. 48 patients (5%) did not specify . When anWhen characterizing the pain attacks of the 894 patients reporting pain in general, 173 patients (19%) had pain multiple times a day, 50 (6%) once daily, 137 (15%) multiple times per week, 38 (4%) once per week, 138 (15%) multiple times per month with only 73 patients (8%) reporting of pain once a month and 155 patients (17%) less than monthly. 130 patients (15%) did not specify .When comparing CD and UC patients in the group of CD patients presenting with pain 104 patients (21%) had pain multiple times a day, 26 (5%) once daily, 86 (18%) multiple times per week, 19 (4%) once per week, 66 (14%) multiple times per month, 36 (7%) once per month and 82 (17%) less than monthly. 65 (13%) did not specify. In the analysis of the UC patients 66 patients (17%) had pain multiple times a day, 21 (5%) once daily, 49 (13%) multiple times per week, 19 (5%) once per week, 64 (16%) multiple times per month, 36 (9%) once per month and 69 (18%) less than monthly. 64 patients (16%) did not specify. More CD patients  reported of pain multiple times per week compared with UC  to hours , in 11% (102 patients) the pain duration was seconds and in 10% (93 patients) up to 3 days with only 73 patients (8%) reporting pain over more than 5 days. 153 patients (17%) did not specify the pain attacks . In the The median pain intensity in the past 4 weeks was 2/10. 235 patients (26%) had no pain in the previous 4 weeks. The greatest pain intensity in the last 4 weeks was a median of 3/10.Most of the 894 patients who reported pain suffered from abdominal pain , followed by back pain in 342 patients (38.3%), knee pain in 258 patients (28.9%) and hip pain in 231 patients (25.8%). 220 patients (24.6%) reported headaches, 132 patients neck pain (14.8%), 204 patients (22.8%) pain in the hand and finger joints, 90 patients (10.1%) reported pain in the elbows, 192 patients (21.5%) shoulder pain and 16.6% (148 patients) reported pain in the feet/ankles. 312 patients (34.9%) did not specify .In the subgroup analysis there was no relevant difference in the pain localization in the CD and UC patients .The majority of the 894 patients reporting of pain , received pain medication. Only 116 patients (13%) had physiotherapy. 216 patients (24%) received no pain treatment.When accessing the kind of medical pain treatment, the majority of 37% (333 patients) used Acetaminophen. Only 112 patients (13%) used NSAID and COX-2 inhibitors were used seldom . Opioids or Metamizole were used in 16% (142 patients) while 239 patients (27%) did not specify . In a suWhen assessing the impact on quality of life 528 patients (59%) of the patients had an impact on the duties of daily life, with a median of 3/10 , 329 (37%) had no impact and 37 (4%) did not specify. 513 patients (57%) had an impact on their work with a median of 4/10 , 344 (39%) had no impact on work, 37 (4%) did not specify. The general quality of life was significantly lower in patients suffering of pain compared to those without pain  p<0.0001).Using data from 1,263 SIDBCS patients we showed prevalence of pain in IBD patients was high. With 71% of our patients reporting pain, pain is present in many more patients than generally assumed. This is consistent with data from Germany were a high prevalence of pain (87.9%) was found in a much smaller cohort of 334 patients. When coFor a significant number of patients with IBD chronic pain is a growing problem and has a large impact on quality of life. Due to its frequency and possible direct relation to a hypersensitivity state due to the inflammatory process, it has even been proposed to add chronic pain to the list of extraintestinal manifestations of IBD, 45.Furthermore, we showed that pain is a longstanding problem for the majority of the patients affected. 52% of patients experiencing pain >5 years with only 2% reporting pain since less than 1 month. In a subgroup analysis comparing CD and UC, statistically more UC patients only suffered from pain in the last 1–2 years compared to CD (p = 0.0026). This reflects that pain in UC may be of shorter duration compared to CD. A possible explanation for this could be that CD patients, due to its higher prevalence of EIM, suffer more frequently of longer a duration of pain in comparison to UC . In an eThe main pain localization was abdominal pain (59.5%), but a large proportion of patients also suffered from back pains, joint pains and headaches. Back pain was reported in 38.3% and 28.9% of patients suffered of knee pain. Furthermore 22.8% of IBD patients had pain in the hand and finger joints and 21.5% reported shoulder pain. This is in line with the literature showing that arthropathies are the most common extraintestinal manifestations in IBD, 6–16. OWhen characterizing pain, the majority of patients reported pain attacks with no pain in between (55%). On the other hand, a substantial part of patients (40%) reported not being pain free between the pain attacks or even having a constant pain.Notably, we show that pain is undertreated: one fourth of the patients reporting pain did not receive pain treatment. Given the high prevalence of joint and back pain and the know efficacy of physiotherapy it is surprising that only 13% of the patients received physiotherapy. When acOur study has strengths, but also limitations. A clear strength is the large cohort that we studied with 1263 completed questionnaires, making it, to our best knowledge, the largest study on this topic in IBD up to date.The limitations of our study however, include that, due to the study design and the fact that we did not control unreturned questionnaires we can face a reporting bias. Patients who actually suffer from pain due to IBD might want to share their feelings, while patients that do not suffer would be more enticed to completely discard the questionnaire. This would result in overestimation of pain prevalence in our study. Against this limitation speaks, that compared to the German study by Schirbel et al. with 387 IBD patients, which had a response rate of 96.8%, our prevalence of pain was not higher.In summary, using a nationwide patient cohort of IBD patients we have demonstrated that prevalence of pain in IBD patients is high and that it is present in many more patients than generally assumed. Further more pain has a substantial impact on the HRQOL. Thus, an increased awareness is mandatory to address this frequent complication in the course of IBD. Furthermore, it underlines the importance of pain management in IBD.S1 FilePain questionnaire sent to the patients of the Swiss IBD Cohort Study (SIBDCS) in German.(DOCX)Click here for additional data file.S2 FilePain questionnaire sent to the patients of the Swiss IBD Cohort Study (SIBDCS) in French.(DOCX)Click here for additional data file.


Background: Our objective was to identify the clinical, laboratory and radiological characteristics of febrile urinary tract infections (UTI) in men and to focus on the value of flank pain in these men managed in an ambulatory care system. Methods: A network was designed to manage men with febrile UTI without hospitalization according to an algorithm designed with different specialists. The patients’ characteristics were prospectively recorded and each patient was followed up until completely cured. We artificially divided patients into two groups. Group 1: men without flank pain diagnosed as prostatitis and a second group (Group 2) of men with flank pain or provoked flank pain more likely to have a pyelonephritis. Groups were compared to find arguments to differentiate prostatitis to pyelonephritis. Results: 350 men were included in the study, half of these men reported urinary symptoms . The negative predictive values of the nitrite and leukocytes test were poor alone or in combination. The renal ultrasound was never informative. None of the patients failed to respond to the treatment. No difference was found between groups. Conclusions: Laboratory test results and radiological features had a poor predictive value. Men with suspected pyelonephritis did not evolve differently from those with suspected prostatitis. Monitoring and treatment of men with febrile UTI does not seem to depend on the existence of a pyelonephritis suspected after the presence of a lumbar pain. Ambulatory management of febrile UTI is feasible and safe, requiring an efficient network for patient’s surveillance. Acute genitourinary tract infections such as acute prostatitis (AP) represent a significant problem in urological practice. Unfortunately, very few data have been published regarding this subject. In the U.S., AP is the most common urological diagnosis in men under 50 years of age, representing 8% of consultations . AntibioA network was designed to include general practitioners (GP), private biological departments and private radiological departments to manage febrile urinary infections without hospitalization. Each patient was managed “at home” by scheduling clinical examinations, laboratory tests and imaging using the network. All of the GPs involved in the group were educated on how to use an algorithm initially built with specialists and were asked to enter information into a database. Treatments were defined as successful if symptoms disappeared in less than 72 h and if no recurrence was observed within one month. Herein, we present the entire clinical, laboratory, radiological and bacteriological data for men with acute febrile urinary infection treated between May 2005 and December 2012 as part of the SphereS. We analyzed 350 men who presented with febrile urinary infection. The data were collected prospectively in a customized database and were retrospectively analyzed. We included all men who were recruited by their GP because of suspicion of a febrile urinary infection (fever and urinary symptoms); however, men with suspected urethritis  were excluded from the study. Once enrolled in the study, none of the men were excluded from the final analysis. We artificially divided patients into two groups. Group 1: men without flank pain diagnosed as prostatitis and a second group (Group 2) of men with flank pain or provoked flank pain more likely to have a pyelonephritis. Groups were compared to find arguments to differentiate prostatitis to pyelonephritis.t-test.Continuous variables were reported as the mean value plus or minus the standard deviation. The sensitivity, specificity and positive and negative predictive values were calculated for several variables. We used chi-square analysis and alternatively, when indicated, Fisher’s exact test and Wilcoxon for non-parametric comparison of means. The significance of the difference between groups was estimated by way of a two-tailed Student’s Three hundred and fifty men were enrolled in the study. The patient characteristics are summarized in All men were referred to their GP because of suspicion of febrile acute urinary tract infection. All men were referred because of fever higher than 38 °C, and half of these men reported urinary symptoms .3  patients had neutrophil counts exceeding 8000/mm3 .E. coli, and 5.7% tested positive for Proteus mirabilis. The sensitivity of the nitrite test was 67%, and the specificity was 57%; the sensitivity of the leukocyte test was 94.3%, and the specificity was 5.8%. The addition of the of the nitrite test results marginally improved the sensibility of the leukocyte test; however, the specificity remained low. The positive predictive value of a positive nitrite test and of the combination of a positive nitrite and a positive leukocyte test were respectively 90.1% and 86.1%. The negative predictive values of the nitrite and leukocytes test were poor alone or in combination.No difference was found between groups in terms of urine dipstick results. Among patients with urine dipsticks showing negative for leukocytes and nitrite, only 5.5% had a negative urine culture, 82.8% tested positive for The urine dipstick was positive for leukocytes and nitrite in 97.9% of patients and was negative for both in 2.1% of the cases of positive urine culture .Twenty four patients (6.8%) had a postvoiding volume greater than 80 mL. In the remaining cases, the renal ultrasound was not informative .p = 0.011).Two cases of renal dilation were found; however, only one patient exhibited pain in his flank. Stones were more often found in patients with spontaneous or provoked flank pain (p < 0.001). None of the patients failed to respond to the treatment. Men returned with apyrexia in mean 2.7 days ± 1.6 days. Only three men (one in group 1 and two in group 2) required hospitalization during follow up. No difference was found between groups. Men with suspected pyelonephritis did not evolve differently from those with suspected prostatitis. Monitoring and treatment of men with febrile urinary tract infection does not seem to depend on the existence of a suspected pyelonephritis suspected after the presence of a lumbar pain.Overall, 92.8% of patients were treated with fluoroquinolones. The mean duration of treatment was 22.9 ± 6.6 days . We could argue that the diagnosis of AP was suggested by geriatricians because of positive bacterial cultures in men with indwelling catheters. DREs suggesting AP are not routinely described  [et al. reported that approximately 37% of men with AP report previous UTI [The clinical characteristics of acute prostatitis are poorly described in the published literature ,3. The mC reactive protein (CRP) and leukocyte levels were elevated in 96% and 74% of men with AP, respectively . We founBlood cultures were not available in our study. In a previously published study, blood cultures were analyzed for acute prostatitis patients . Blood cIn a previous study, urine dipsticks were used to test 422 men with urinary infections . The autPost-voiding residual volumes were not different between groups in our study. In the Etienne study, only 14% of patients followed by an infectious disease specialist had post-voiding residual volume measurements done, and 21% of patients had postvoiding residual volume measurements done if followed by a urologist . This reTo our knowledge, this is one of the largest studies analyzing a substantial amount of data in an important population of men with febrile UTI. Data were collected prospectively and analyzed retrospectively. The network increases the follow up of patients with routine phone calls and specialist visits if the evolution of UTI is unfavorable or if the patient experiences recurrent episodes. The data examined in this study emphasized that the laboratory tests or radiological exams should be performed accurately. The national and international infectious disease committee should take into account these results to provide new recommendations for the diagnosis and treatment of men UTIs. The question about the diffenciation between AP and prostatitis remains unsolved. We can argue that no difference was found between men with flank pain and men without flank pain in term of clinical or biological data. Stones were, however, more frequently found on ultrasound if men complain of flank pain.This study, conducted using data from patients with febrile UTI, revealed that the most common clinical features are fever with urinary discomfort. No differences were found between men with or without flank pain, except for stones, which were more frequently diagnosed on ultrasound if men complained of flank pains. Laboratory test results and radiological features had a poor predictive value. Men with suspected pyelonephritis did not evolve differently from those with suspected prostatitis. Monitoring and treatment of men with febrile urinary tract infection does not seem to depend on the existence of a suspected pyelonephritis suspected after the presence of a lumbar pain. The results of this study will be very useful for the development of future guidelines concerning the management of febrile UTI in men. Ambulatory management of febrile UTI is feasible and safe, requiring an efficient network for patient surveillance.


Epidural steroid injection (ESI) is one of the most commonly used treatments for radiculopathy. Previous studies have described the effectiveness of ESI in the management of radiculopathy. However, controversy exists regarding the route that is most beneficial and effective with respect to the administration of epidural steroids, as both transforaminal (TF) and caudal (C) routes are commonly used.This analysis reviewed studies comparing the effectiveness of TF-ESIs with that of C-ESIs in the treatment of radiculopathy as a means of providing pain relief and improving functionality. This meta-analysis was performed to guide clinical decision-making.The study was a systematic review of comparative studies.A systematic literature search was performed using the PubMed, EMBASE, and Cochrane Library databases for trials written in English. The randomized trials and observational studies that met our inclusion criteria were subsequently included. Two reviewers, respectively, extracted data and estimated the risk of bias. All statistical analyses were performed using Review Manager 5.3.Six prospective and 2 retrospective studies involving 664 patients were included. Statistical analysis was performed utilizing only the 6 prospective studies. Although slight pain and functional improvements were noted in the TF-ESI groups compared with the C-ESI groups, these improvements were neither clinically nor statistically significant.The limitations of this meta-analysis resulted primarily from the weaknesses of the comparative studies and the relative paucity of patients included in each study.Both the TF and C approaches are effective in reducing pain and improving functional scores, and they demonstrated similar efficacies in the management of lumbosacral radicular pain. The chemical mediators originating from either a ruptured disc or from neighboring structures, and the mechanical deformation caused by either a herniated disc or excessive tissue proliferation, which results in both nerve root compression and nerve irritation, represent 2 crucial factors that provoke inflammatory responses and increase sensory neuron susceptibility, resulting in radicular pain.4 and it has since become one of the most commonly utilized conservative interventions for radiculopathy.5 Steroids are used to reduce inflammation in the epidural space.10 LESI is performed via a transforaminal (TF), caudal (C), or interlaminar (IL) approach in the lumbar spine; these approaches offer different advantages and disadvantages, which may result in different outcomes.14 The TF approach is perhaps the most favored because the injection site is adjacent to the nerve root, and only a small volume of medication is required for injection.15 The C route is both the easiest and the safest route and also seems to provide the most favorable analgesic effects. However, this approach requires relatively large volumes of medication and is less specific to the site of pathology.16 Previous studies have described the effectiveness of these methods in the management of radiculopathy.22 The utilization of lumbosacral TF-ESIs has increased annually at a rate of 20.3%, which is markedly higher than the 2% annual increases noted with respect to lumbosacral C-ESI and IL injection based on analysis of data from the Centers for Medicare and Medicaid Services (CMS) collected between 2000 and 2011.23Lumbar epidural steroid injection (LESI) was first suggested as a conservative treatment for radicular pain in 1952 by Robecchi and Capra,27 Some relevant research has already been conducted comparing the effectiveness of the TF versus IL route and the effectiveness of the 3 routes, but no comparison of the TF versus C route has been performed. However, it remains debatable whether TF or C approaches should be utilized in clinical practice, and no definitive standards pertaining to LESI exist. It is therefore necessary to compare the clinical efficacies of different procedures to generate data that can be used to formulate clinical guidelines. Our goal was to systematically review, grade, and perform meta-analysis of existing comparative studies. In this review, we compared the effectiveness of TF-ESIs and C-ESIs with respect to pain and functional improvements in the treatment of radiculopathy.Transforaminal ESI seems to be more effective at reducing pain, improving functionality, and preventing spinal surgery, based on the data reported in previous studies and systematic reviews.Ethical approval of this study was not necessary, as systematic review and meta-analyses do not involve patients.The standards set by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were used to construct this systematic review. The 27-item checklist and 4-phase flow diagram of PRISMA were both consulted.The PubMed, EMBASE, and Cochrane Library databases were searched from January 1966 through June 2015 to identify studies comparing TF-ESIs with C-ESIs for the treatment of lumbosacral radicular pain. The search terms included “Transforaminal Epidural Steroid Injection,” “Caudal Epidural Steroid Injection,” “Efficacy of Transforaminal Epidural Steroid Injection,” “Efficacy of Caudal Epidural Steroid Injection,” “Transforaminal versus Caudal Epidural Steroid Injection,” “Efficacy of Transforaminal versus Caudal Epidural Steroid Injection,” and “Selective Nerve Root Block versus Caudal Epidural Steroid Injection.”References from each article directly comparing the 2 approaches, in addition to review articles discussing the efficacies of the 2 approaches, were cross-referenced to identify additional relevant studies.For inclusion in the systematic review, the articles were required to meet the following eligibility criteria: patients >18 years) suffering from lumbosacral radicular pain; papers reporting the results of clinical studies evaluating TF-ESIs and C-ESIs; patients followed for a minimum of 2 weeks; and papers published in English before June 2015. Randomized controlled trials (RCTs) were identified as the primary studies for analysis. For inclusion in statistical analysis, the patients in a particular study must have been randomized to either TF or C groups. Studies were excluded from the analysis if they did not include standardized pain scores within specific follow-up periods or perform statistical analyses of their results. The inclusion criteria for each study are listed in Table 8 years sThe included RCTs were evaluated for the risk of bias, which included assessments of adequate sequence generation, allocation of concealment, blinding, incomplete outcome data, and freedom from other biases, using the Cochrane Risk of Bias Tool. The judgment of each entry involved assessing the risk of bias as “low risk,” “high risk,” or “unclear risk,” indicating either a lack of information or uncertainty over the potential for bias. Two reviewers independently assessed each RCT, and any disagreements were resolved by discussion and consensus.The data were extracted independently by 2 authors (LL and HZ). Any disagreements were resolved via discussion among the 3 reviewers . The characteristics of each study were extracted, including the last name of the first author, publication year, study design, number of patients, mean age, baseline pain and functional scores, duration of symptoms, injection level  was the primary outcome measure of the effectiveness of the ESIs. The secondary outcome measure was functional improvement (Oswestry Disability Index [ODI]).t test under a random-effects model. The differences were displayed using a forest plot. The continuous data from the studies were reported as standardized mean differences (SMDs) with 95% confidence intervals (CIs). The I2 statistic28 (ranging from 0% to 100%) was applied to quantify between-study heterogeneity that was not attributed to chance . Heterogeneity was interpreted via 8 statistics, which are used to analyze pain relief and functional improvement at 2 weeks, 3 months, 6 months, and 12 months, and the results are presented in forest plots , slightly better pain relief was observed in the TF groups at 2 weeks  reported complete pain relief, whereas 16 patients (53.3%) reported partial pain relief and 13 patients (43.3%) reported no relief. Thirty patients received TF-ESIs; 9 patients (30%) reported complete pain relief, whereas 16 patients (53.3%) reported partial pain relief and 5 patients (16.7%) reported no relief.Five prospective studies32 and Manchikanti et al34 followed their patients for 12 months and provided data regarding pain relief. The pain level reported in these studies was 2.95 ± 1.759 versus2.60 ± 1.540 and 4.10 ± 1.391 versus4.30 ± 1.644 in the TF and C groups, respectively. No statistically significant differences in pain scores between the treatment groups were noted.Galhom and al-Shatouri37 of the 6 prospective studies reported data on functional level rise. All 5 studies measured functional level using the ODI. Meta-analyses were performed at 2 weeks, 3 months, 6 months, and 12 months after the injections ; however, no clinically or statistically significant differences in efficacy between TF-ESIs and C-ESIs were noted over longer periods of time. Five prospective studies measured patients’ functional improvement and observed superior results in the TF groups at both 3 and 6 months after treatment. However, no significant differences were observed between the 2 types of injections.27 However, controversy exists regarding which route is the most beneficial and effective in the administration of epidural steroids. Previous studies and systematic reviews of ESIs have been hampered by their designs, baseline differences between the treatment groups, inadequate sample sizes, and an inability to confirm the location of the injection because fluoroscopy was not used.Several studies have indicated that ESIs improve patients’ pain and functionality.39 However, C-ESI requires a high-volume injection (8–12 mL) to ensure that the epidural space is filled and that the drug is delivered to each vertebral level.40 By contrast, TF-ESI requires only a small volume (1–2 mL) and allows for the medication to be administered directly to the dorsal root ganglion.41Most experts believe that TF-ESI offers a more target-specific steroid delivery to the dorsal root ganglion and is therefore superior to C-ESI.42 Patients with a high disease burden43 and psychopathology,45 such as depression and other forms of psychological distress, may also have a worse outcome. Furthermore, a prolonged disease duration, lack of employment, smoking, the nature of a patients’ symptoms, and so on may affect the ESI results. And these may be the reasons why these included prospective studies generated different outcomes.Several factors may clinically influence the outcomes of ESIs, thereby influencing the choice of the route of administration. With increasing age, the risk of developing radicular pain is higher. Older patients also tend to experience worse outcomes.48 show that ESIs combined with local anesthetics get a better effect on pain relief and functional level in managing chronic low back pain. Therefore, it is necessary to add the local anesthetic during the injections.Most ESIs are used combining with local anesthetics. The local anesthetics are thought to have analgesic effects during the process of injection, which is beneficial for patients to relax. In these days, some researches53 C-ESI is both the safest and the easiest epidural injection, and it does not always require fluoroscopic guidance. For the C route, there may be an increased risk of needle tip placement anterior to the sacrum or into the rectum, whereas TF-ESI carries an increased risk of trauma to the nerve root during needle placement, which may result in paraplegia in rare instances.54 Further, all types of steroids may cause adverse events and complications, such as osteoporosis, necrosis of bone, fluid retention, steroid myopathy, weight gain, and so on. Therefore, clinicians should pay attention and use caution when performing ESIs.The 2 most common causes of complications of ESIs are related to inaccurate needle placement and medicine administration. Both types of injections may cause complications such as headache, soreness at the injection site, and toxicity.2 documented both change of pain score and functional score after only 2 weeks, although their patients were followed for 24 weeks. Ploumis et al30 also performed a randomized, blinded, prospective trial, and recorded changes in patients’ pain and functionality between 2 weeks and 6 months after treatment. These studies observed similar outcomes in degree of pain relief, but contrasting results in functional level at 2 weeks . However, over 12 months (a longer time period), C-ESIs exhibited a slightly better impact on both pain and functionality. Ackerman and AhmadOne limitation of this study was its small sample size, which made assessing the effectiveness of the interventions on different patient outcomes difficult. The small sample size may be attributed to the inclusion and exclusion criteria utilized in this review, as the studies that were ultimately included in this systematic review did utilize consistent inclusion and exclusion criteria. Another limitation of this review was that corticosteroid dosages differed among the included studies; in some cases, the dosages differed between groups enrolled in the same study. Third, many of the studies lacked data regarding complications, additional injections, the need for local anesthesia, and the need for fluoroscopic guidance.55 Our study has demonstrated that TF-ESI and C-ESI are similarly effective in managing lumbosacral radicular pain. Before selecting a steroid injection route for the management of radicular pain, the benefits and risks of the approaches discussed herein must be taken into consideration, as the outcomes of this review were not significantly different between the 2 treatment groups. Additional studies must therefore be performed to guide clinical decision-making.Most clinicians believe that TF-ESI exhibits superior efficacy and is being performed with increasing frequency, although this belief seems to be unsubstantiated.


Pain in osteoarthritis (OA) has been classically attributed to joint structural damage. Disparity between the degree of radiographic structural damage and the severity of symptoms implies that factors other than the joint pathology itself contribute to the pain. Peripheral and central sensitization have been suggested as two of the underlying mechanisms that contribute to pain in OA. The aim of this study was to explore in symptomatic knee OA patients, the structural changes assessed by magnetic resonance imaging (MRI) that could be used as markers of neuropathic pain (NP).This cross-sectional observational pilot study included 50 knee OA patients with moderate to severe pain (VAS ≥40) in the target knee. The presence of NP was determined based on the PainDETECT questionnaire. Among the 50 patients included, 25 had PainDETECT score ≤12 (unlikely NP), 9 had PainDETECT score between 13 and 18 (uncertain NP) and 16 had PainDETECT score ≥19 (likely NP). WOMAC, PainDETECT, and VAS pain scores as well as knee MRI were assessed.P <0.001), function (P <0.001), stiffness (P = 0.007) and total (P <0.001) scores as well as higher VAS pain score (P = 0.023), and PainDETECT scores. Although no difference was found in the cartilage volume between groups, the presence of meniscal extrusion in both medial (P = 0.006) and lateral (P = 0.023) compartments, and presence of meniscal tears in the lateral compartment (P = 0.011), were significantly associated with increasing PainDETECT score. Moreover, the presence of bone marrow lesions in the lateral plateau and the extent of the synovial membrane thickness in the lateral recess were associated with increasing PainDETECT scores .Data showed no significant difference in demographic characteristics between the three groups. However, a positive and statistically significant association was found between the WOMAC pain (In this study, meniscal lesions, particularly extrusion, were found to be among the strongest risk factors for NP in knee OA patients.NCT01733277. Registered 16 November 2012.ClinicalTrials.gov  Pain in osteoarthritis (OA) has been classically attributed to joint structural damage, and nearly all therapeutic strategies have been aimed at treating the pain derived from the joint. However, disparity between the degree of radiographic structural damage and the severity of symptoms, such as pain and functional limitations in OA patients, implies that factors other than the joint pathology itself, also contribute to the pain. Peripheral and central sensitizations have been suggested as two of the underlying mechanisms of pain in OA. Indeed, OA patients have been found to experience both nociceptive and neuropathic pain (NP) to varying degrees -5. The pThis cross-sectional study thus aimed at investigating, in knee OA patients with moderate to severe pain  ≥40 mm), the structural changes assessed by magnetic resonance imaging (MRI) that could be used as markers of uncertain (PainDETECT >12) or likely (PainDETECT ≥19) NP.This study is a multicentre, cross-sectional, single-blinded observational pilot study. The presence of NP was determined based on use of the PainDETECT questionnaire (score 0 to 38) -11. The Subjects aged 40 years and older, followed in ambulatory clinics, with a diagnosis of primary knee OA according to the American College of Rheumatology criteria, of Kellgren-Lawrence (KL) radiological grades 2 and 3, and being symptomatic for at least 1 month out of the 3 months preceding the study, and VAS pain score while walking on a flat surface ≥40 mm, were eligible to be included in the study.Subjects were excluded from the study if they met any of the following criteria at the beginning of, or during, the study: other bone or articular diseases (antecedents and/or current signs), isolated knee OA in the lateral compartment only defined by joint space loss, surgery on the target knee, comorbidities that restrict knee function, having taken any investigational drug within 30 days or 5 half-lives (whichever is greater) prior to entering the study, inability to give informed consent, meeting any contra-indication related to MRI, having taken either corticosteroids  or intra-articular injections of hyaluronic acid in the target knee during the 26 weeks preceding the study.This study, registered at ClinicalTrials.gov (NCT01733277), was approved by the ethics committee IRB Services , Aurora, ON, Canada. Written informed consent was obtained from all participants.The clinical characteristics included demographic data, the Western Ontario and McMasters Universities Osteoarthritis Index (WOMAC) questionnaire  and the MRI of the target knee was performed no more than 21 days after the study visit. The MRI acquisitions were performed on Philips Achieva 3 T units . The MRI examination comprised the following sequences: sagittal proton density-weighted fast spin-echo sequence with fat suppression (PD-FSE) ; sagittal three-dimensional intermediate-weighted fast spin-echo sequence with fat suppression (VISTA-SPAIR) ; and axial T1-weighted gradient-echo sequence non-fat suppressed (In-Out Phase) .The cartilage volume was measured using the VISTA-SPAIR sequence and values determined with ArthroLab’s fully automated quantitative MRI (qMRI) system  as described . MeniscaP value ≤0.05 was considered statistically significant. All statistical analyses were done using SAS software, version 9.3 .This exploratory study aimed to correlate the knee OA structural changes as assessed by quantitative and semi-quantitative MRI scoring systems  with the presence of NP, by comparing the three study groups stratified according to PainDETECT scores . Comparison of the demographic characteristics of the three study groups was carried out using the Kruskal-Wallis test for continuous variables and the chi-square test (or Fisher’s exact test) for categorical variables. Comparison of the clinical and MRI characteristics was carried out using the Jonckheere-Terpstra trend test for continuous variables and the Cochran-Armitage trend test for categorical variables. A The demographic characteristics of the three groups did not differ Table . No statP <0.001), function (P <0.001), stiffness (P = 0.007) and total (P <0.001) scores and higher VAS pain (P = 0.023) and PainDETECT scores  and lateral (P = 0.023) compartments was found to be significantly associated with increasing PainDETECT scores (Table P = 0.011) was also significantly associated with PainDETECT scores  .et al. [A higher WOMAC pain score in OA patients with a neuropathic component of pain has been previously reported  and coulet al.  to the eet al. . The comThe mechanisms underlying NP-like symptoms in OA are still poorly understood. OA pain likely includes both nociceptive and neuropathic components. It has been suggested that the local damage to innervation as well as other joint structures may cause damage to peripheral nerves . In thisThe association of knee pain with meniscal extrusion assessed by MRI in OA patients was recently reported . A few pIt is noteworthy that very few data exist regarding the relationship between meniscal lesions and NP in knee OA and this is a promising field of future research. The present study is particularly interesting as it is the first to report a clear association of meniscal lesions, more specifically extrusion, with NP. The finding of the association between the presence of meniscal extrusion and the PainDETECT scores makes this structural alteration a definite marker of NP. This finding is clinically relevant for various reasons. First, it argues for a pathophysiological relationship between NP and meniscal extrusion in knee OA and supports the examination for meniscal extrusion in knee OA patients with NP. This suggests that in daily practice, the predominance of a neuropathic component in such patients should encourage physicians to consider the use of MRI to establish a proper diagnosis. Second, a diagnosis of meniscal extrusion may help to identify knee OA patients who are more susceptible to benefit from a treatment aimed at controlling their symptoms more specifically. There is hope that this ‘personalized therapeutic management’ would avoid the prolonged use of anti-inflammatory drugs or even narcotic analgesics, preventing potential side effects, and that the patients would have a better response to treatment. Future research might explore whether managing meniscal extrusion, for instance with arthroscopic meniscal repair or resection, in such patients with NP would be beneficial.This pilot study has limitations, the first being that it was an observational study and not a randomized controlled trial, the second being the arbitrary determination of the sample and, third, the diagnosis of NP was based solely on the PainDETECT questionnaire. However, as no gold standard test for NP diagnosis in OA is yet recognized, this questionnaire was used, as in many previous OA studies ,29,30, sIn summary, the findings of this study show that in knee OA patients, meniscal lesions are a definite major risk factor for NP. BMLs and synovitis also seem to be, to a certain extent, associated with NP; however, a definite study is needed to fully address the question, as they may be contributing factors in association with others.


Simultaneous bilateral TKA (SBTKA) has been a favored surgical solution due to reduced costs and patient suffering. The purpose of the present study was to investigate the risk factors of asymmetric recovery in patients who underwent SBTKA and whether that affected quality of life. A total of 187 patients undergoing SBTKA were included. During this study, patients underwent physical examination  of knee and quadriceps strength) and completed three surveys . Our results reveal interlimb asymmetries existed at least two years postoperatively. Between-limb differences in active ROM, quadriceps strength, and VAS pain scores were significantly detected in our study. Risk factors included being female, being older, and having high BMI and high levels of anxiety and depression; different diagnosis and different component size could be risk factors. Finally, interlimb differences in VAS pain scores and active ROM were negatively associated with SF-36 scores. However, interlimb differences in swelling and quadriceps strength were unrelated to SF-36 scores. Risk factors of asymmetric recovery should be evaluated and appreciated due to their significant impact on patients’ quality of life. Before performing SBTKA, clinicians should consider possible risk factors and inform patients of asymmetric recovery between limbs, which could help decrease the unnecessary consultations and postoperative patient dissatisfaction. Simultaneous bilateral total knee arthroplasty (SBTKA) has been favored due to lower costs and less surgical trauma and complications compared to staged bilateral TKA ,2,and coTo the best of our knowledge, almost all of the published studies related to asymmetry in TKA have been based on participants who accepted unilateral or staged bilateral TKA –15.DespiThrough a defined time period, all consecutive patients with bilaterally symptomatic osteoarthritis were enrolled in this prospective study. Patients signed written consent before the first assessment, which contained information on risk, complications, and quadriceps strength as measured by a machine as well as necessary clinical visit follow-up. The study was approved by the ethics committee of 252 hospital of Chinese PLA (No. Ortho-22) and was carried out in accordance with the Declaration of Helsinki. This patient was excluded if he or she (1) had high risks for SBTKA following the rigorous selection, (2) had had obvious asymmetry in appearance, quadriceps strength, pain, knee girth or active ROM prior to surgery  before the skin incision routinely and then every 8 hours for 24 hours. Epidural anesthesia was used in SBTKA procedure. All operations were performed by the same surgical team. Cemented cruciate-retaining prosthesis  with patellar resurfacing was used for all patients in this study. The approach to expose the capsule was median incision. The osteotomy of femur and tibia were intra or extra-medullary guided fashion, respectively. Recollected blood was filtered and washed in the recovery room and then retransfused into the patient within 6 hours. The drainage tube was promptly extracted at postoperative 24h. The pneumatic tourniquet was sequentially applied to both sides at 300mm Hg. Both were used from the beginning of femur osteotomy to the end of tibia osteotomy and then released following closure of the joint capsule. Patients received a patient-controlled analgesic (PCA) pump during postoperative 48 hours. For relieving postoperative pain, all patients received routinely diclofenac sodium  orally during their hospital stay and tramadol  after discharge. Preventive anticoagulant therapy (10mg rivaroxaban every day) began within 12 hours after operation and continued for 14 days.Active ROM is of importance to postoperative functional training and recovery following TKA; it is an objective indicator of recovery progress. Therefore, we selected it as the primary clinical outcome to describe the characteristics of interlimb asymmetry and its potential determinants.Patients were seated in an electromechanical dynamometer  to measure maximum quadriceps strength  with both knees flexed at 75°. They were asked to extend their knee as much as possible for 3 s. Two attempts of maximal contraction were performed and the greater one was recorded. The quadriceps strength of both limbs was measured and recorded. Patients sat with their hands on their laps on a chair that was designed to stabilize the body and minimize synkinetic movements.A Lafayette Gollehon extendable goniometer was applied to measure active ROM. Patients in supine position were asked to slide their heels toward the buttocks and to flex their knees maximally. Then knee ROM was recorded.In addition to those above, we recorded swelling and pain scores. Pain intensity was evaluated by a 10cm visual analogue scale (VAS) in which 0 represented no pain and 10 represented the worst imaginable pain intensity.Between-limb difference greater than 20% in active ROM was defined as asymmetry in this study. Assessments of these four parameters were performed at seven time points .SF-36 survey was recorded at 12 months postoperatively to measure patients’s quality of life. Before discharge, we routinely performed radiograph evaluations and then excluded operation-related factors that produced interlimb asymmetry.We listed possible risk factors to construct a survey questionnaire to the best of our best knowledge. It consisted of basic demographic information,diagnosis, physical examination, comorbid conditions, psychological factors, and operational details. Psychological factors included anxiety and depression, which were measured by Hospital Anxiety and Depression Scale (HADS) (dichotomized < 8 and ≥ 8). This questionnaire was completed by the patients prior to surgery.We analyzed interlimb asymmetry through comparing the dominant and non- dominant side. Specifically, the dominant side was defined by better performance in active ROM. Between-limb asymmetry was examined using a paired t-test. In addition, we examined the linear relationship between patients’ magnitude of asymmetry and scores on the SF-36 using a Pearson correlation. Multiple logistic regression analysis was used to determine the risk factors for asymmetry in pain. Two-way ANOVAs were used to detect whether a significant relationship existed between time intervals and gender, BMI, and other variables. Data are shown as mean ± SD or as percentages. It was assumed that all these statistics were normally distributed. Statistical significance was set at p-value ≤0.05. Statistics analyses were performed by SAS Statistical Software 9.1.3.From May 1, 2013 to October 1, 2014, a total of 250 participants underwent SBTKA and 63 cases were excluded. Particularly, 32 patients had been considered as interlimb asymmetry before surgery by our definition; 4 patients had infection in one knee; 8 patients were unable to complete our survey due to cerebral stroke or mental disorder; 7 patients accepted different TKA’components; 2 patients were diagnosed with symptomatic DVT; 4 patients showed severe arteriosclerosis obliterans in one limb; and 6 patients were missing during follow-up. Ultimately, 187 patients were analyzed in this study. Preoperative and operative details are shown in There was no significant difference between limbs in quadriceps strength, pain, active range of motion (ROM), and swelling prior to SBTKA. However, there were significant differences in quadriceps strength, VAS pain scores, and active ROM between limbs during follow-up . NotablyInterlimb differences in VAS pain scores and active ROM were significantly negatively associated with SF-36 scores . HoweverPatient-reported questionnaires aim to assess pain, quality of life, and function in activities of daily living. Studies have found that psychological factors greatly affect the results of these questionnaires , 21. ForAsymmetrical load distribution in a lower extremity after surgery has been revealed to broaden the gap between limbs and increase the risk of asymmetrical recovery progress . HoweverAlthough in most cases both knees are diagnosed with degenerative osteoarthritis, there is a possibility that the specific etiology of each knee is different. For instance, one side with traumatic osteoarthritis may indirectly lead to secondary osteoarthritis in the contralateral side due to uneven distribution of weight load. Different etiology has different pathophysiological process , which cAlthough bilateral osteoarthritis was usually symmetric in deformity, it is difficult to guarantee the same component size applied in bilateral TKA. Brown reported that the prevalence of femoral component asymmetry was 6.7–9.2% and tibial component asymmetry was 0–8.7% among SBTKA procedures . ComponeOur results suggest that there is significant asymmetric recovery between limbs for SBTKA patients just as there is with staged bilateral TKA and unilateral TKA. The present study provides novel evidence that interlimb difference in clinical outcomes after SBTKA appear early after surgery and may extend for two years postoperatively or longer. Interlimb asymmetry can be detected mainly by using the measures of active ROM, pain level, and quadriceps strength.The level of interlimb differences in VAS pain score and ROM were negatively associated with scores on the SF-36. Finally, in the adjusted multivariate logistic regression analysis, we observed that age, female, high BMI, high anxiety and depression, different diagnosis, and different component size were significant risk factors.We offer these possible explanations:In addition, we investigated the effect of interlimb difference after SBTKA on quality of life.Specifically, between-limb differences in pain scores and active ROM were negatively associated with SF-36 scores. However, there was no significant relationship between difference in quadriceps strength, swelling, and quality of life. Previous studies have showed that the sensing system in the human body was more sensitive for the pain feeling and stereoscopic perception , 17. ThuThe present study is the first to investigate the question of why interlimb asymmetry occurs and how to improve recovery after SBTKA. The practical implication of this research lies in the identification of risk factors for patients with significantly asymmetrical recovery. This can help medical teams provide better preoperative education and give at-risk patients a realistic expectation of unsynchronized recovery between limbs, which would help to avoid unnecessary postoperative consultation. Secondly, precise knowledge of the natural history of interlimb difference in clinical outcomes following TKA is of fundamental importance to prevent unsatisfactory results. Meanwhile, these data can help physical therapists and surgeons design more scientific and reasonable exercise protocols to reduce the extent of interlimb differences. Specific treatments targeted at different limbs to balance between-limb asymmetry are necessary.Limitations in this study should be acknowledged. Definition of “asymmetry” in this study was based on 20% interlimb difference in active ROM of knee. The asymmetry of our definition can affect the present conclusions. Secondly, self-reported questionnaires (VAS pain scores and SF-36) were used to assess interlimb difference in pain and quality of life pre- and postoperatively. Self-report data leads to less persuasive conclusions due to recall bias and subjectivity of measurement. Lastly, patients were required to describe pain of each knee to the best of their ability. There were different degrees of potential bias resulting from patients’ ability to distinguish sensations in each knee. Limitations mentioned above open the door for future research and improving these aspects may deepen related conclusions.To our knowledge, this is the first study to compare between-limb asymmetry after SBTKA and to detect potential risk factors. Our results demonstrated that significant differences exist between limbs in active ROM, pain level, and quadriceps strength. Significant relationships between interlimb differences in active ROM, pain scores, and quality of life were also determined. Identifying high-risk patients for asymmetry potentially helps to explain between-limb asymmetry for surgeons and physical therapists, to avoid unnecessary medical expense,and to decrease patient dissatisfaction. Further research is needed in this area to study whether individuals may benefit from treatments targeted at different limbs to balance between-limb asymmetry after surgery.