All patients were evaluated using the Visual Analog Scale (VAS), Foot Function Index (FFI), and the Roles and Maudsley score (RM) before and after treatment. An evaluation was performed on average 6 months after treatment. Results: This study included 79 RFA patients  with a mean age of 55.8 ± 9.6 years and 80 ESWT patients  with a mean age of 49.1 ± 9.5 years. There was a significant decrease in VAS scores after treatment in both the RFA and ESWT groups . The reductions in FFI pain, FFI activity restriction, FFI disability, and RM scores were significant in both groups, although the scores after treatment were lower in the RFA group. Conclusions: This study demonstrates that ESWT and RFA significantly reduced pain, disability, and activity restriction in the treatment of plantar fasciitis in patients with calcaneal spurs. ESWT proved particularly effective in alleviating pain, whereas RFA had more pronounced effects on reducing disability and activity limitations. The choice of treatment should be based on the patient’s specific complaints.Background and Objectives: We aimed to compare the effectiveness of ESWT  and RFA  on pain, disability, and activity limitation in the treatment of plantar fasciitis in patients with calcaneal spurs. Materials and Methods: Patients who apply to Orthopedics and Traumatology and Physical Medicine and Rehabilitation departments with a complaint of heel pain are included in this retrospective study. We included patients diagnosed with calcaneal spurs who received treatment with ESWT ( There are many causes of heel pain. Heel pain occurs as a result of systemic diseases or as a result of diseases that concern the bone, soft tissue, and nervous system. Among the causes of heel pain are tendonitis, bursitis, tarsal tunnel syndrome, neuroma, peripheral nervous system diseases, fractures, benign and malignant tumors of the bone, bone cysts, osteomyelitis, and systemic and rheumatological diseases ,2. PlantMany factors are proposed in the etiology of CSs. These factors include age, sex, obesity, excessive exercise, foot structure and biomechanics, foot injuries, rheumatoid arthritis, diabetes, osteoarthritis, and gout, which can also be considered as contributing to plantar fasciitis . A physiConservative methods are the first step of treatment. Rest, soft shoes, insoles, exercises, and non-steroidal anti-inflammatory drugs are conservative methods used for treatment. In patients who do not respond to conservative treatment, methods like steroid or PRP (platelet-rich plasma) injections, physical therapy modalities, ESWT , and RFA  are commonly used. In cases resistant to conservative and minimally invasive methods, surgical methods can be used. Surgical treatment can lead to complications and is not a definitive method of treatment ,14,15. TExtracorporeal shock wave therapy (ESWT), which has been shown to be an effective and safe treatment for CS, has been widely used recently . ESWT haRadiofrequency ablation (RFA) is a symptomatic, pain-relieving treatment option. RFA administration is used in the management of many painful conditions that require ablation of different nerve settlements, such as trigeminal neuralgia, complex regional pain syndrome, chronic postoperative pain, cancer pain, hyperhidrosis, facet joint pain, and knee osteoarthritis ,22. It iIn our study, we compared the effects of RFA and ESWT methods, of plantar fasciitis in patients with calcaneal spurs on pain and quality of life. In our literature review, we did not come across any other studies comparing the effectiveness of ESWT and RFA in the treatment of plantar fasciitis in patients with calcaneal spursThis retrospective study was conducted on patients who complained of heel pain, received ESWT treatment at the Physical Medicine and Rehabilitation Clinic (FTR), and received RFA treatment at the Orthopedics and Traumatology clinic between August 2021 and September 2022. As a result of clinical examination and direct X-ray films patients with calcaneal spur were included. Patients who have not benefited from conservative treatments involving oral anti-inflammatory medication, insoles, and corticosteroid injection have not been treated for any medical treatment, injection, physical therapy, or surgical treatment, and RFA and ESWT have been selected for the past four weeks. Patients for whom pre-and/or post-treatment records, direct X-ray radiographic images, and historical data could not be fully obtained were excluded from this study. Data from 395 patients were evaluated, and 236 patients were not included in this study. This study consisted of 79 patients from the RFA group and 80 patients from the ESWT group. This study was agreed to by the Fırat University Ethics Committee.® RPW 2  in the physiotherapy unit, with 3 weekly sessions repeated over 3 weeks, each consisting of a maximum of 2000 pulses at a frequency of 10 Hz. ESWT pressure was adjusted according to the patient’s pain resistance. The applicator was placed over the maximum sensitivity point. Local or regional anesthesia was not applied. The treatment was performed with a cold gel. The second group was selected from patients who attended the Orthopedics and Traumatology clinic with plantar fasciitis pain due to calcaneal spurs, did not respond to conservative treatment, and did not undergo ESWT. The second group was treated with radiofrequency ablation (RFA). After the heel area was sterilized in the patient supine position, pain localization was detected by palpation, and local anesthesia was provided to the heel medial site with 1 mL %2 Lidocaine. In the desired location, a 10 mm needle cannula was inserted. The needle of the cannula was removed, and a 100 mm long, 22-gauge RFA (radiofrequency ablation) needle  was inserted into the cannula. First, patients were provided with a 1.5 V stimulus, and it was observed that there was no motor stimulation, such as fasciculation or movement of the toes. It was confirmed that the impedance was between 300 and 500. Thermal RFA was applied for 120 s at 60–80 °C, with the temperature increasing up to 80 °C. Thermal RFA was applied for a total of 180 s, with an additional 60 s while monitoring the impedance. In patients who reported severe pain at 80 °C, the temperature was lowered to 60 °C. Considering that patients may experience mild pain (at a tolerable level for the patient) if they do not feel any pain below 60 °C, the procedure was continued between 60 °C and 80 °C. Thus, the effectiveness of the procedure was monitored in communication with the patient. RFA is applied to patients who have not been relieved by conservative or steroid treatment. An evaluation was performed on average 6 months after the treatment.There were two groups of patients. The ESWT group was selected from patients who were presented to the FTR clinic with plantar fasciitis pain due to calcaneal spurs, did not respond to conservative treatment, and did not receive RFA. The first group was treated with ESWT  scores with a range of 100 mm were used to assess pain intensity, and Foot Function Index (FFI) and Roles and Maudsley score (RM) scores were used to assess foot pain, disability, and activity limitation.Visual Analog Scale (VAS): A table used for digitizing values that cannot be measured numerically. The patient’s condition is marked in a 100 mm line. It is a common, reliable test and can be applied easily.Foot Function Index (FFI): Created to assess the impact of foot pathology on function in terms of pain, disability, and activity limitation. FFI is an index of 23 items divided into 3 subscales. The FFI has been reviewed for test reliability .The Roles and Maudsley score (RM): A subjective evaluation of the patient’s pain and activity limitations:  .No complications  were observed with RFA and ESWT.This study was approved by the local ethics committee .The accession numbers will be provided during the review.p-value of <0.05 was considered statistically significant.The data were analyzed using the statistical package for social sciences (SPSS), version 22 . Quantitative data are expressed as average ± standard deviation (SD), while qualitative data are expressed as numbers. The Shapiro–Wilk test was used for normality distribution. The distribution of the normality was checked using the independent T-test. In the univariate analysis of the variables in the study, the Kruskal–Wallis and Wilcoxon tests were used according to the variable type and the assumptions. The differences between the categories of the observations in the categorical variables were tested using the chi-squared test Wilcoxon test in the analysis of dependent data, which was applied. A p: 0.095, p: 0.795). The results are shown in This study included 79 RFA patients  with a mean age of 55.8 ± 9.6 years and 80 ESWT patients  with a mean age of 49.1 ± 9.5 years. The mean BMI values were 28.52 ± 3.8 in the RFA group and 28.7 ± 2.6 in the ESWT group. Regarding age and BMI, there were no significant differences between the patient groups (p: 0.00). The decreases in FFI pain, FFI activity restriction, FFI disability, and RM scores were significant in both groups, but the scores after treatment were lower in the RFA group. The before and after treatment measurement values for the patient groups are given in There was a significant decrease in VAS scores after treatment in both the RFA and ESWT groups , as well as the pre-treatment VAS, FFI pain, and RM scores, were similar in both groups . Similar improvements in pain scores were observed in both the ESWT and RFA groups.In this study, we compared the effectiveness of ESWT and RFA in the treatment of calcaneal spurs. Although many methods have been suggested for the treatment of CSs, there is still limited evidence. The study investigating the efficacy of ESWT and RFA has not been identified in the literature, so we believe that our study adds to the literature on CS treatment. It was observed that both treatment methods were effective in reducing pain, and although the FFI disability and activity limitation scores of patients in the RFA group were higher, the post-treatment scores were significantly reduced compared to ESWT. The BMI values of our patients , or fluoroscopy can be used during the procedure. However, successful results have also been reported without the use of USG or fluoroscopy . In thisAccording to our results, RFA is especially in patients with severe pain and limited daily activity, who do not respond to conservative treatment can be a useful alternative to surgery or ESWT. Erken et al. suggested that RFA is an effective alternative treatment option for patients with resistant plantar fasciitis who do not respond to other conservative treatments . SimilarIn patients with calcaneal spurs, PF causes pain and difficulty in daily work. ESWT and RFA are preferable methods for patients who do not benefit from conservative methods of treatment. Our study’s strength is that it is the first to evaluate RFA and ESWT in calcaneal spurs. The RFA patient group had higher VAS and FFI scores. Therefore, we could not clarify which method could be more useful. Studies comparing the two methods should be made between groups with the same VAS and FFI scores. Our work is retrospective. We should also say that the follow-up time is short, and different results can be achieved in long-term follow-up.According to our results, both methods are beneficial, and the choice of treatment should be based on the patient’s complaints and needs. Our results have shown that, according to RFA, ESWT also showed a significant reduction in pain. ESWT, a non-invasive technique, can be selected for patients with pain at the forefront. On the other hand, RFA can be preferred by patients with more physical activity limitations. We think that the improvement in functional scores in RFA is a safe method that is preferable to ESWT in patients with physical activity limitations.As a result, ESWT appears more effective in VAS scores, and RFA appears more effective in functional scores.


Chiari Malformation Type I (CM) includes a range of cranial abnormalities at the junction of the skull with the spine, with common symptoms including pain and headaches. Currently, CM pain is managed medically through anti-inflammatory drugs, muscle relaxants, and opioids, while surgical management includes posterior fossa decompression. Given the adverse effects of opioid use, and an ongoing opioid epidemic, there is a need for safe, non-opioid alternatives for clinical pain management. This systematic review was performed to provide an update on the current literature pertaining to the treatment of CM pain with non-opioid alternatives. A literature search was performed in June 2022 utilizing the PubMed and Google Scholar databases, and articles were identified that included information regarding non-opioid pain management in CM patients. A total of 90 articles were obtained from this search, including 10 relevant, drug-specific studies. Two independent reviewers selected and included all relevant articles based on the chosen search criteria to minimize bias risk. Currently available treatments for neurosurgical pain management include anticonvulsants, corticosteroids, NSAIDs, anti-inflammatory drugs, NMDA receptor antagonists, local anesthetics, nerve blocks, scalp blocks, and neuromuscular blocks. While more information is needed on the use of non-opioid pain management, the present literature provides potential evidence of its efficacy amongst the CM patient population, on account of the success that non-opioid pain management has demonstrated within other neurological pain syndromes. Further research into non-pharmacological pain management would also benefit the CM population and could be generalized to related conditions. Chiari malformation comprises a range of cranial abnormalities at the junction of the skull with the spine, commonly affecting the posterior fossa and hindbrain . It is cAt present, Chiari malformation is managed using a combination of medical and surgical strategies. Medical therapy is used to provide symptomatic pain relief through non-steroidal anti-inflammatory drugs and muscle relaxants, whereas surgical intervention is typically implemented in patients with extreme or worsening neurological symptoms, usually through a posterior fossa decompression with or without duraplasty . With a Managing pathological pain, such as that observed in patients with CM, remains a challenge largely because available therapeutics have limited efficacy and often cause severe adverse effects. While opioid analgesics are commonly used to manage and/or treat myriad clinical pain conditions, their use is limited due to harmful side effects including reduced GI motility, nausea, vomiting, problems with urinary retention, and increased tolerance and dependence. With long-term use, adverse effects include oversedation and increased intracranial pressure. These deleterious effects have often resulted in suboptimal pain management for neurosurgical patients . Given tNovel interventional and peripheral regional techniques are in development to specifically target the pathophysiological pain demonstrated by different neurosurgical patient populations, including those with Chiari Malformations. To minimize patients’ exposure to the risks of opioid use, physicians have established and implemented the use of multimodal analgesics. A multimodal regimen refers to the use of two or more medications from different classes to achieve pain relief . This tePresently, common non-opioid pharmacological agents for neurosurgical pain management include anticonvulsants  , corticoAs all data came from public sources, this study was not human subject research and did not require IRB review or informed consent. We performed a search in June 2022 of the PubMed and Google Scholar databases to identify articles pertaining to non-opioid pain treatment in the Chiari Malformation patient population. For background information, the search keywords utilized included “pain treatment”, “pain management” AND “chiari” OR “chiari malformation”. For drug-specific information, the search keywords utilized included “non-opioid”, “nonopioid”, “anticonvulsant”, “antidepressants”, “local anesthetic”, “exparel”, “bupivacaine liposome”, “anticholinergic”, “botox”, “botulinum toxin”, “cannabinoid”, “cannabis”, “marijuana”, “CBD”, “THC” AND “chiari” OR “chiari malformation” with a date range between 1900 and 2022. Species was specific to humans. Concomitant conditions and/or anomalies  were allowed; however, all patients must have had a CM diagnosis. We included full-text publications that examined the use of non-opioid therapeutics for pain management amongst CM patients. Exclusion criteria included publications that were not categorized as an article, review, case report or series, case study, proceedings paper, or early access by the database criteria, and articles not published or translated into English. Case studies reporting on labor pains in CM patients were not included, as parturition pain demonstrates a confounding variable. We determined eligibility by reading the abstract of each study and eliminated those that did not satisfy the inclusion criteria. Full copies of the remaining articles were then obtained through our institution’s electronic library. Two reviewers (AB and AK) read these studies independently and determined those to include based on discussion. The same two reviewers then extracted data independently, to minimize the risk of bias, based on the predetermined study parameters and removed any duplicates. If the two reviewers disagreed, a third independent reviewer was sourced to reach a consensus about the study’s eligibility. All PRISMA guidelines pertaining to the reporting of systematic reviews were adhered to.A total of 90 article results were obtained from this search. Ten relevant, drug-specific studies were identified and included . ArticlePreviously demonstrated pathophysiological similarities in models of epilepsy and neuropathic pain have justified the use of anticonvulsant drugs in the symptomatic management and/or treatment of neuropathic pain . VasphiaVivas and colleagues provide a case series of five pediatric patients who underwent CM type I decompression with the placement of a dural graft complicated by posterior fossa hygromas and hydrocephalus that were successfully managed nonoperatively . The fivIn contrast, in 1998, Demols and colleagues reported a case of intracranial hypertension (IIH) in the presence of an Arnold–Chiari malformation . Here, aPrasad and colleagues have previously reported that local anesthetics and peripheral nerve blocks are commonly used for both surgical and nonsurgical analgesia . TypicalLiposomal Bupivacaine (LB), marketed as “Exparel”, is an emerging treatment for headache pain associated with CM. Exparel is a local anesthetic used intra-operatively during CM decompression surgery and has a longer bupivacaine hydrochloride release time than standard bupivacaine . The benA study put forth by Lu et al. in 2020 analyzed a population of pediatric CM patients who underwent decompression surgery, and either did or did not receive one dose of liposomal bupivacaine post-operatively . The groA very recent study, published in May 2021 by LoPresti and colleagues, also examined the effects of liposomal bupivacaine in pediatric CM patients. The patients in this study ranged from 0–18 years old, had all undergone CM decompression surgery between January 2017 and July 2019, and either did or did not receive an intrawound injection of liposomal bupivacaine . The useIn 2018, Levin et al. reported a case wherein a 32-year-old woman at 36 weeks gestation and a past medical history of CM type I presented with an intractable headache . She wasBotox (Botulinum neurotoxin) represents a well-characterized and acceptable form of non-opioid pain management for chronic migraines and is an emerging therapeutic option for other types of primary headache, trigeminal neuralgia, neuropathic pain, and a number of additional pain conditions . SubcutaFelício et al. report the case of a 31-year-old woman presenting with neurofibromatosis type I who developed right-side hemifacial spasm . With maThese same authors, Felício et al., published a retrospective analysis evaluating five patients with CM type 1 and hemifacial spasm . Three oMarijuana has been used medicinally since ancient times. While it is now known to have calming, pain-relieving, and non-addictive properties, only recently have states such as Pennsylvania and New Jersey approved the drug for medicinal use. Pain is a qualifying condition for use in both states, and many patients with Chiari Malformation use medicinal marijuana to relieve their pain symptoms. The predominant bioactive compounds in cannabis are called cannabinoids. Two types of cannabinoids are tetrahydrocannabinol (THC) and Cannabidiol (CBD). THC is known to have psychoactive properties while CBD has many medicinal benefits including anti-inflammatory and antipsychotic properties .Journal of Neurological Sciences, by Brugliera and colleagues, reported a novel case involving “therapeutic cannabis for pain management in a patient with CM type 1 during a concomitant SARS-CoV-2 infection” [A recent publication in the Among the various craniocervical junction malformations, Chiari malformations are of particular interest given their prevalence and the intensity of their symptoms ,34. GiveTherapeutically, there are two strategies that can be implemented to help manage CM-associated pain. The first, surgical therapy, is used to decompress the foramen magnum and is indicated for patients demonstrating intractable symptoms. The second, non-surgical therapy, is designed to specifically target and relieve the symptoms caused by neuropathic pain . Of noteSeveral methods of non-surgical therapy may often be used in conjunction with surgical therapy, either intra- or post-operatively, to reduce surgical pain and/or to minimize CM pain that was not adequately addressed through surgery. CM patients may seek further non-surgical and non-opioid intervention when surgery or other treatments have failed in alleviating their symptoms. In a 2019 study performed by Garcia and colleagues, it was noted that CM patients reported high levels of psychological symptoms, such as depression and anxiety, regardless of whether or not they had received decompression surgery . While tIn the published medical literature, there is an overall lack of robust research regarding non-opioid pain management in the Chiari Malformation patient population. By increasing this fund of knowledge, other under-researched patient populations may benefit, as the results and treatment options may be generalizable across varying pain conditions. In addition to pharmaceutical non-opioid pain management, non-pharmaceutical interventions can also play a role in the overall management and improvement of quality of life in CM patients. Data on the use of non-pharmacological interventions on pain are also lacking and may include options such as physical therapy and occupational therapy; these methods can be combined with non-opioid pharmacologic agents to provide a wide array of treatment options that can be personalized to the patient.Limitations of our study include the heterogenous Chiari Malformation patient population and the limited number of studies that have comprehensively evaluated the use of non-opioid therapies in this niche subset of neurosurgical patients. Of note, no relevant articles regarding the use of antidepressants for pain management in CM patients were found. Case studies comprise much of the information that is currently available regarding non-opioid pain management in CM type I patients. This demonstrates a need for focused systematic clinical trials to assess the value and effectiveness of non-opioid pharmacological therapies for the management and/or treatment of pain in CM patients. In addition, the authors recognize that not all possible keywords were employed in the initial search process, which may have limited the studies that were found and included in this review. Additional keywords that may be of interest for future studies include “psychotherapy”, “alternative medicine”, “acupuncture”, and/or “homeopathic”.Several evidence-based, non-opioid treatments for neurological pain management currently exist, including a number that have been tested in patients with Chiari Malformation Type I. However, there remains a major scarcity of literature pertaining to non-opioid pain treatment in CM patients. More population-specific research is needed before wider conclusions can be drawn about the efficacy of these treatments for this unique patient population. Due to the ongoing opioid epidemic, the increasing prevalence of CM , and the


Dear Editor,International Journal of Surgery in 2022. The authors observed the effectiveness of local anesthetic injection (LAI), abdominal local anesthesia injection (IPLA), and transabdominal plane block (TAPB), and no local anesthetic controls on postoperative pain, and compared the analgesic efficacy of these methods1. The results showed that intraoperative local anesthesia can effectively control postoperative pain, especially TAPB can better manage postoperative pain. Many aspects of this study are well done. The authors conducted a double-blind, randomized controlled study. They had 160 patients who underwent laparoscopic cholecystectomy for cholecystitis and used statistical analysis to rule out confounding factors that might influence postoperative pain, such as age, gender, previous operations, body mass index and number of trocars. In addition, they openly discussed the limitations of their study. All of these are advantages of research design. We can learn from their examples. However, we believe that there are several important questions in this study that are not well addressed.It was with great interest that we read the article published in the 2. Second, whether to place drainage tube during the operation. In clinical work, some gallbladder inflammation is severe, the closure of the gallbladder duct is not satisfied usually need to indentation drainage tube, to facilitate postoperative observation whether there is bleeding or bile leakage and other manifestations. The drainage tube is also an important factor that causes postoperative pain at the mouth of the drainage tube and mechanical stimulation3. Therefore, the location of gallbladder retrieval and the placement of drainage tube are likely to cause differences in postoperative VAS  and satisfaction scores. However, this study did not report the relevant situation of these details during the operation.The authors mention in the ‘Materials and methods’ section, ‘All patients underwent laparoscopic cholecystectomy by two experienced surgeons by placing four trocars in the mid-abdomen and upper abdomen.’ However, we know that some of the steps and details of the operation may lead to different levels of postoperative pain. First, which port to retrieval the gallbladder from during the operation. Trauma to the abdominal wall during gallbladder removal is known to cause postoperative pain, and the gallbladder is usually removed through a puncture hole in the upper abdomen and umbilical cord. However, the location of removal can lead to different postoperative pain. Some studies have shown that gallbladder retrieval from the umbilical port with lower port site pain than gallbladder retrieval from the upper abdominal port in patients undergoing laparoscopic cholecystectomyet al.4 reported that preoperative anxiety may cause intraoperative hemodynamic problems, increase patients’ need for postoperative analgesia, and reduce patients’ postoperative satisfaction. If the design of this study included preoperative assessment of patients’ anxiety, such as Spielberger’s State-Trait Anxiety Inventory (STAI) to use, the study would provide more useful data for effective pain control after laparoscopic cholecystectomy.In addition, the subjects of this study were patients undergoing laparoscopic cholecystectomy due to symptomatic cholelithiasis. In fact, chronic abdominal pain is very common in these patients and often causes psychological disorders such as anxiety. These psychological factors before surgery are also related to the degree of pain after surgery, and can affect patient satisfaction. Bayrak Despite these problems, this study provides a direction for addressing postoperative analgesia of the gallbladder. However, further research is needed to confirm the main findings of this study. Finally, we are very grateful to Ergin and his colleagues for their tremendous efforts in carrying out this very important study.Not available.This is a commentary.Not available.J.W.: manuscript preparation; Z.C.: critical revision and submission.The authors Zhichao Chen and Jianfeng Wei declare that there are no conflicts of interest.This is a commentary.Jianfeng Wei.This is a commentary; no data needs to be stated.Not available.


To examine the clinical efficacy of prophylactic metoclopramide in reducing the incidence of nausea and vomiting in emergency department (ED) patients with acute pain who were treated with intravenous tramadol.We conducted a single-center randomized, double-blinded, placebo-controlled trial. A total of 99 ED patients presented with acute pain were recruited. Sixty-four patients were randomized, 31 patients in the treatment arm and 33 in the control arm. Overall, there were no significant differences in baseline characteristics between treatment arm and control arm. Only one patient within each arm reported having nausea symptom. No patients reported vomiting episode. There was no statistically significant difference in the proportion of patients with nausea or vomiting symptoms between the two groups . The administration of prophylactic metoclopramide may not provide additional benefit in reducing the occurrence of nausea and/or vomiting episode in ED patients with acute pain treated with intravenous tramadol.Trial registration Randomized clinical trial TCTR20220525001; registration date: 21 October 2021. Retrospectively registered. Acute pain is a common chief complaint in the emergency department (ED) , 2. IntrStrategies were proposed to reduce the side effects of intravenous opioid . One of This study was a randomized, double-blinded, placebo-controlled trial conducted in the Emergency department of Lampang Hospital, Thailand from October 2021 to March 2022. The study protocol was registered in Thai Clinical Trials Registry (TCTR) [TCTR20220525001]. The Institutional Review Board of Lampang Hospital approved the study protocol (CERT NO. 103/64).We include patients who presented to the ED during the study period who fulfilled the following criteria: (1) aged more than or equal to 18 years, and (2) presented with any type of acute painful conditions, including headache, musculoskeletal pain, renal colic, gallbladder colic, with moderate to severe intensity ). Patients with one of the following conditions were excluded from the study: pregnancy or lactation, contraindicated to tramadol or metoclopramide, had nausea or vomiting symptoms upon study inclusion, or at the time of randomization, patient who were at high risk for extrapyramidal side effects, patients who were treated with drugs other than intravenous Tramadol, patients who could not provide informed consent, and patients with previous antiemetic use.We collected baseline data on age, sex, underlying disease, location of pain, and severity of pain recorded in NRS.All included patients were enrolled and randomized into one of the two groups in a 1:1 ratio, either prophylactic metoclopramide plus intravenous tramadol (treatment arm) or placebo plus intravenous tramadol (control arm), using a computerized blocked randomization generated by an independent research assistant. The randomization sequences were also stratified based on age groups and sex. Allocation concealment was performed using sequentially-numbered opaque sealed envelopes (SNOSE). The sealed envelopes were opened just after the patients were enrolled into the study and all baseline data were collected. The study interventions were provided immediately after randomization.Patients randomized into the treatment arm received 50 mg intravenous tramadol and 10 mg intravenous metoclopramide. In contrast, patients in the control arm were administered with 50 mg intravenous tramadol and a matching placebo of intravenous metoclopramide, consisting of 10 ml of normal saline solution (NSS). The treatment was prepared and administered by ED nurses who were not involved in the outcome assessment. Patients, attending physicians, data collectors, and outcome assessors were all blinded to the study assignments.For both arms, an intravenous tramadol (50 mg/1 mL) was diluted with 19 mL of NSS, summed up to a total volume of 20 mL, and was slowly pushed within 2 min. After intravenous tramadol was delivered, a 10 mL of NSS was used for flushing the infusion line. Then, either an intravenous metoclopramide (10 mg/2 mL) diluted with 8 mL of NSS or a matching placebo containing 10 mL of NSS were administered within the next minute for the treatment and control arm, respectively.The primary outcome was the occurrence of nausea and/or vomiting within 2 h after randomization . Nausea The primary outcome was assessed by independent health care providers who were blinded to the treatment assignments. The outcome assessors evaluated the presence/absence of nausea or vomiting symptom, the severity, the need for rescue therapy or anti-emetic agent, and the pain NRS every 30 min until patient disposition or 2 h after randomization, which ever were reached first.According to our routine observations, the incidence of nausea and vomiting in ED patients with acute pain treated with intravenous tramadol was approximately 30%. We assumed that administration of intravenous metoclopramide would result in a reduction of nausea and vomiting incidence by 25 percentage points compared to placebo. To achieve statistical power of 80% at 5% one-sided significance level, with an anticipated 10% drop-out rate, a total of 64 patients was required.Categorical data were described with frequency and percentage. Mean and standard deviation (SD) for Normally-distributed numerical data, and median and interquartile range (IQR) for non-Normally distributed numerical data. The normality of data was justified based on histogram and Shapiro–Wilk test. The incidence of nausea and/or vomiting between the two treatment arms were compared using Fisher’s exact probability test (one-sided). The analysis was performed using the intention-to-treat principle where all patients were included in the analysis and were analyzed according to which group they were initially assigned. P values less than 0.05 were considered statistically significant differences. All statistical analyses were conducted using Stata 17 .A total of 99 ED patients presented with acute pain were recruited. Sixty-four patients were randomized, 31 patients in the treatment arm and 33 in the control arm  (Table In this randomized placebo-controlled trial, we have found that administration of prophylactic metoclopramide may not provide additional benefit in reducing the occurrence of nausea and/or vomiting episode in ED patients with acute pain treated with intravenous tramadol.The results of our study were, however, in contrast to that of Kim et al. in 2019 . In theiThis study was the first randomized, placebo-controlled trial to be conducted in Thai patients who presented to ED with acute pain symptoms and treated with intravenous tramadol. Although we could not provide firm conclusions on the benefits of prescribing prophylactic metoclopramide, our study still serves as an important contradicting evidence that addresses this clinically relevant question in a wider spectrum of patient population.The results of our study should be interpreted in light of limitations. First, although the required sample size was achieved, the incidence of nausea and vomiting symptoms in our sample was unexpectedly low, and the anticipated effect of prophylactic metoclopramide over placebo was not observed. It is obvious that our predetermined study size was not sufficiently powered. This low incidence issue was also observed in previous studies in which a higher potency of opioid was used –24 and nIn conclusion, the clinical benefit of prescribing prophylactic metoclopramide to reduce the occurrence of nausea and vomiting symptoms in ED patients with acute pain treated with intravenous tramadol was not identified in this trial. Therefore, prescribing prophylactic metoclopramide to reduce the occurrence of OINV to all ED patients may not be necessary in settings with low OINV incidence, such as those where preventive administration strategies have already been implemented. Further studies should focus on the potential efficacy of prophylactic antiemetics in patient domains with a higher baseline OINV risk.


Enhanced recovery after surgery (ERAS) leads to less morbidity, faster recovery, and, therefore, shorter hospital stays. The expected increment of primary total hip arthroplasty (THA) in the U.S. highlights the need for sufficient pain management. The favorable use of short-lasting spinal anesthesia enables early mobilization but may lead to increased opioid consumption the first 24 h (h) postoperatively.In a retrospective study design, we compared conventional THA with postoperative immobilization for two days (non-ERAS) and enhanced recovery THA with early mobilization (ERAS group). Data assessment took place as part of the “Quality Improvement in Postoperative Pain Treatment project” (QUIPS). Initially, 2161 patients were enrolled, resulting in 630 after performing a matched pair analysis for sex, age, ASA score (American-Society-of-Anesthesiology) and preoperative pain score. Patient-reported pain scores, objectified by a numerical rating scale (NRS), opioid consumption and side effects were evaluated 24 h postoperatively.p = 0.002), accompanied by significantly higher opioid consumption (p < 0.001). Maximum and minimum pain as well as side effects did not show significant differences (p > 0.05).The ERAS group revealed higher activity-related pain (This study is the first to analyze pain scores, opioid consumption, and side effects in a matched pair analyses at this early stage and supports the implementation of an ERAS concept for THA. Taking into consideration the early postoperative mobilization, we were not able to detect a difference regarding postoperative pain. Although opioid consumption appeared to be higher in ERAS group, occurrence of side effects ranged among comparable percentages. Leading to less morbidity, faster recovery and, therefore, shorter hospital stays, enhanced recovery after surgery programs (ERAS) experience growing acceptance and worldwide adoption , 28, 35.Due to demographic change, current predictions expect an incremental rise of primary THA in the U.S. by 284% in 2040, reaching a preliminary peak of 1.429.000 procedures annually . AlthougThe beneficial use of short-lasting spinal anesthesia in ERAS concepts enables early mobilization . Due to In a matched pair analysis of 630 patients, comparing conventional with enhanced recovery THA with early mobilization, we aimed to evaluate patient-reported pain, opioid consumption, and side effects 24 h postoperatively.2, immobilization in a wheelchair or need for a wheeled walker were excluded. Furthermore, refusal to participate, disorientation, sedation, visitors during data assessment or cognitive dysfunction represented criteria for exclusion. An independent, special trained pain nurse interviewed the patients 24 h postoperatively. A validated 16-item questionnaire was used, asking for minimal and maximum pain since surgery on a numerical rating scale  to document postoperative pain management and occurrence of complications. Satisfaction with pain management and participation in pain management was objectified by an inversed NRS . The file reporting demographic data as well as the patients’ questionnaire is provided under the following URL: https://www.quips-projekt.de/services/dateien and attached to the document.Data assessment took place between 2009 and 2021. In a retrospective study design, in total, 2161 patients receiving primary THA at our university hospital were included. Criteria for inclusion were cementless primary THA and fully orientated patients, older than 18 years. Patients with BMI > 40 kg/mPatients in both groups received primary THA via a modified Watson–Jones approach without transection of muscular tissue . PatientThe established ERAS concept for primary THA consisted of local infiltration analgesia, special anesthesia, and a targeted postoperative treatment protocol: Patients received education before the operation in terms of pain management and gait training by physiotherapists. They were trained to walk with crutches in advance and educated what the limitations in mobilization they have to expect directly after the operation. One hour preoperatively, participants were administered a non-steroid-anti-inflammatory-drug (etoricoxib 90 mg). Every patient received a short-lasting spinal anesthesia  combined with the intravenous application of dexamethasone (8 mg). In addition, patients received tranexamic acid intravenously (1 g) as well as topically (2 g). Intraoperatively local infiltration analgesia  was administered periarticular, femoral, acetabular, and subcutaneously. No drains were placed in the operating field. Patients were immediately allowed full weight-bearing and first mobilization was carried out 2–3 h postoperatively at an Intermediate Care Unit (IMC). Every patient received intensive physiotherapy by a special trained physiotherapist for half an hour two times a day. Patients were encouraged to use a special developed exercise course with the aim to improve range of motion and balance.In contrast to the ERAS concept, patients receiving conventional primary THA (non-ERAS) received neither gait training, nor analgesic medication directly before the operation. A long-lasting spinal anesthesia was performed . Intraoperatively, neither local infiltration analgesia, nor tranexamic acid or dexamethasone was administered. Wound drains were consequently applied. At the earliest, patients were mobilized for the first time the day after the operation. Postoperative partial weight-bearing was allowed. Physiotherapy took place once a day.Data acquisition was performed as part of the Quality Improvement in Postoperative Pain Treatment project (QUIPS), a nationwide German benchmarking initiative for postoperative pain . IncludiThe present study was conducted in agreement with the ethical standards of the Declaration of Helsinki (1975). A member of the study crew informed every patient orally as well as in written form about the study. Every participant signed the informed consent before enrollment. Participation was voluntary with possible withdrawal at any time. The ethics committee as well as the data security board of the Jena University Hospital  approved the data acquisition for the QUIPS project. The study is registered in the DRKS with number DRKS00006153 (WHO register).hi-square test and nonparametric Mann–Whitney U. Statistical significance was considered at p < 0.05. Statistically significant data are noted in italics. Statistical analysis was performed with SPSS , Armonk, New York, U.S.).To ensure groups of identical size and cofounders, we performed a 1:1 matched pair analysis, based upon gender, age, ASA, and chronic NRS preoperatively . If therBetween 11/2009 and 11/2021, 1843 patients received conventional primary THA, while 318 patients received THA featuring the described enhanced recovery concept. After performing a 1:1 matched pair analysis for gender, age, ASA, and NRS preoperatively, each group consisted of 315 patients. The flowchart is illustrated in Fig. p = 0.002, Table p = 0.032). Demographic data are noted in Table As result of the matched pair analysis, demographic data of gender, age, ASA, and preoperative pain are almost identical. The duration of surgery appeared to be significantly shorter in the ERAS group than in conventional THA . The ERAS group revealed significantly higher pain scores in activity-related pain . The other functional outcome parameters ranged among comparable values in both groups . The data are noted in Table Patients in the ERAS group revealed significantly higher demand for oral opioids at the IMC unit as well as at ward than the conventional THA group . In summary, taking into consideration the early postoperative mobilization, we were not able to detect a difference regarding postoperative pain. Even though there is statistically difference it might not be clinically different.In addition, although the ERAS group reported significantly more activity-related pain, the difference is not that big and might be from minor clinical importance (NRS activity related: ERAS 3 ± 2 vs. non-ERAS 2 ± 2). Farrar et alrelevant . TherefoCompared to conventional THA, opioid consumption in ERAS group at IMC unit almost doubled. At ward, opioid demand still appeared to be higher than in the non-ERAS group, though less distinctive. One explanation might be the long-lasting effect of opioid spinal anesthesia in conventional THA, in contrast to the short-lasting one in the ERAS group. While the difference is more pronounced at IMC unit, the effect of anesthesia is fading, and it already harmonized more at ward. As described above, the additional stress and pain through early mobilization in the ERAS group have to be taken into consideration and might represent the true cause for the measured difference.Another reason for the high opioid consumption within the first 24 h postoperatively may be the occurrence of rebound pain after regional anesthesia. The phenomenon of rebound pain as a side effect of regional anesthesia was first reported in 2005; nevertheless, its causes are still mainly unclear . It is dSome studies report a significantly higher occurrence of dizziness, nausea, and vomiting in patients receiving fast-track surgery , 20. In p = 0.002). Extended surgery time demonstrates a major risk factor for infections and postoperative complications like delirium [The duration of surgery was significantly shorter in the ERAS group (delirium , 33. Mordelirium . Neverthdelirium , 41. Nevdelirium , 22, 25.The present study features some limitations. First, the study followed a retrospective design. For better comparison we performed a matched pair analysis for sex, age, ASA, and preoperative pain scores to reduce covariate bias. Second, data acquisition only took place at one instance without further assessments and the evaluation of progress is thus missing with regards to the QUIPS-projects study design. Third, there may be a potential selection bias through the novel establishment of the ERAS concept at our university hospital.Although the biggest differences in pain and opioid consumption are expected the first 24 h after the operation, the present study is the first to analyze this in depth in a matched pair analysis. Taking into consideration the early mobilization, we did not detect a difference in postoperative pain comparing conventional THA and THA with an ERAS concept. Although opioid consumption appeared to be significantly higher in the ERAS group, the occurrence of side effects ranged among comparable percentages. In addition, the operation time in the ERAS group was significantly shorter. In summary, this study supports the implementation of an ERAS concept for primary THA.


Neck pain is among the common musculoskeletal problem that hinders a person’s daily activities. Fascial tightness is a familiar cause of chronic neck pain that is often neglected and can further cause neck disability and a limited range of motion.The purpose was to compare the effects of fascia therapy and fascial manipulation on pain, range of motion and function in patients with chronic neck pain.A randomized clinical trial was conducted from February to August 2022 in the Riphah Rehabilitation Centre, Lahore, Pakistan. Fifty-two participants of both genders, aged 18–40 years with chronic neck pain of at least 3–6 months were included. Group A (n = 26) received fascia therapy along with a conventional physical therapy protocol of hot pack, strengthening and stretching, while group B (n = 26) received the fascial manipulation treatment with conventional physical therapy. All the participants were assessed at baseline and after 3 weeks (3 sessions per week). Numeric Pain Rating Scale (NPRS), Neck Disability Index (NDI) and Goniometer (range of motions) were the outcome measures. SPSS 25 was used for the data analysis and normality of the data through the Shaphiro-Wilk test (p > 0.05), and parametric tests were applied.The mean age of group A was 24.82 ± 2.64 years, and group B was 24.17 ± 2.20 years. The independent t-test result showed no significant difference (p ≥ 0.05) in all parameters except in cervical extension and right-side bending (p < 0.05). At the same time, the pair-wise comparison showed significant results (p < 0.05) for all outcome measures in both groups.DBM fascia therapy improved cervical extension and side bending (right) more than the fascial manipulation group.It is concluded that DBM fascia therapy shows more improvement as compared to other group.This study was registered at ClinicalTrials.gov ID: NCT05272111 on 09/03/2022. Neck pain is the fourth most common cause of neck disability and most people recover from it. Neck pain causes can be ruled out with a proper physical exam and history , 2. SomeMany different treatment therapies are there for the improvement of painful symptoms around the neck , which iThe current study focuses on two different treatment techniques for improving chronic neck pain. The first technique is the DBM or Dannis Bois Method fascia therapy technique which French osteopath Prof. Dannis Bois developed. It is a non-manipulative soft tissue therapy technique that involves gentle pressure while stretching the body’s connective tissue. Three steps are involved in this technique: a somatic sense, gentle touch and body movement, which improves the elasticity of the tissues and decreases symptoms of a painful neck –19. The The randomized clinical trial  was conducted at Riphah Rehabilitation Centre, Lahore, Pakistan. After obtaining the ethical approval from the institutional ethics committee with a reference number of REC/RCR & AHS/22/0102. This study was registered at ClinicalTrials.gov ID: NCT05272111 on date 09/03/2022. The sample size of 52 was calculated after adding a 10% attrition rate using the epitool sample size calculator with a 5% variance and 95% confidence interval . Using tParticipants with a history of a recent surgery (3 months prior), neck trauma, systemic or soft tissue disease, pregnancy, radiculopathy and neck instability were excluded from the study. Both groups, A and B, received a three-week treatment session with three sessions per week on alternate days and the same baseline treatment therapy of 10 min hot pack, neck isometrics, and neck stretches in all planes.Group A received the DBM Fasciatherapy, a technique in which very gentle pressure was applied to a person’s body connective tissues. It is a non-manipulative technique in which soft and deep pressure is targeted to the connective tissues or fascia of the body. To apply this technique the patient was comfortably sitting on a seat then through the application of the specialized touch of the therapist, involving the patient’s somatic sense, and the specific body movement of the patient were the three steps that were involved in the fascia therapy. Along with this, the conventional treatment involves the hot pack (10 min), neck flexion, extension, side bending and rotation isometrics , with stretching of the neck flexors, extensors, side benders and rotators  were given. A total of 45 min sessions three times a week on alternate days for three weeks were given to these patients , 19, 24.Group B received the fascial manipulation technique that involves the application of the appropriate manipulation on the specific point of the fascia with limited movement. The patient was comfortably lying on the plinth with the therapist on the head side. The therapist locate the specific points on the fascia anteriorly, posteriorly, and posterolaterally. Then a specific oscillatory manipulative force was applied directly over that point to resolve that fascia tightness. Along with this, the conventional treatment involves the hot pack (10 min), neck flexion, extension, side bending, and rotation isometrics  with neck flexors, extensors, side benders and rotators stretching  were given. A total of 45 min sessions three times a week on alternate days for three weeks was given to these patients , 20, 24.All the participants in both groups were assessed for pain using the NPRS scale. NPRS values ranged from 0 to 10, zero shows no pain and 10 shows worst pain and reliability was ICC = 0.85–0.96 . FunctioDescriptive and statistical tests were applied using SPSS, IBM version 25. For the quantitative variables, mean and standard deviation were calculated. Results of the Shapiro-Wilk test (p > 0.05) showed that the data were normally distributed, so parametric tests were applied to evaluate the effects of fasciatherapy and fascial manipulation on patients with chronic neck pain. The paired t-test shows differences within the group while the differences across the group were shown by the independent t-test and for significant differences, the p-value was set as p ≤ 0.05.After screening 63 patients, 52 participants who fulfilled the inclusion criteria were included in the study. Participants were randomly allocated into two groups using the lottery method. There were 26 participants in group A and 26 in group B, with a mean age of 24.82 ± 2.46 and 24.17 ± 2.20 in groups A and B, respectively. All the participants received treatment for three weeks with three sessions per week on alternate days. The data was analysed using SPSS version 25. There were four dropouts from Group A and three from Group B. The CONSORT flow diagram is shown in Fig. Demographic characteristics are shown in Table Table The current study aimed to compare the effects of two treatment techniques fascia therapy and fascial manipulation. Fascia therapy improved the cervical ranges; extension and right side bending, but there was no difference in other parameters. Fascia therapy and fascial manipulation techniques were equally effective in improving pain, range of motion and function in neck pain management. Both groups were assessed for NPRS, NDI, and cervical ranges. Cervical extension and right-side bending showed significant results (p ≤ 0.05), which means group A (DBM fascia therapy) was more effective, but in the case of all other parameters, there were non-significant results (p ≥ 0.05).In a previous study the fascial manipulation (FM) technique was used on thirty students with neck pain. Both groups were assessed for NPRS, NDI, and cervical ranges. Similar results are shown in a study that fascial manipulation and combination therapy (ultrasound and tens) can be used for neck pain management as both show significant improvement . AnotherThere was a reduction in pain levels and psychological suffering in the patients to whom DBM fascia therapy was given as a part of the treatment , the resThe perception of the clinical utility and awareness of the benefits of using DBM fascia therapy in the management of pain was explored. The self-structured questionnaire was sent to French physiotherapists who were using DBM fascia therapy as a treatment regime for patients with pain. DBM Fasciatherapy-trained physiotherapists who practised it in their clinical settings showed improvement in the symptoms of both physical pain and psychical suffering. This treatment technique resulted significantly in headaches, neck and lower back pain, and migraines , the curFascia therapy and fascial manipulation both positively affect tissues and muscles and relax the body physically and psychologically. The neck region is especially affected when the patient is in stress emotionally. Trigger points and tight muscles lead to severe neck pain, but the myofascial release will benefit both acute and chronic cases.The limitation of this study was the participation of more females in this study and only two males participated. Another limitation was that the duration of treatment was of 3 weeks as in many studies, it ranged from 6 to 8 weeks for better results but in a few studies, 2 weeks was also a suitable period for myofascial release. In future, we can add a long duration of treatment sessions with follow-ups.According to the study findings, DBM fasciatherapy shows more improvement in cervical extension and right-side bending range of motion as compared to the fascial manipulation technique. Although there was no statistically significant difference between the groups in other parameters. Both types of treatment techniques showed clinical improvement in neck pain intensity, disability and range of motion.


Purpose: Intradiscal biacuplasty (IDB) has been proven to be effective for treating lumbar degenerative disc disease (DDD). However, there has not been a reported prognostic factor for IDB. The present study meticulously evaluates the general and radiographic features that may serve as markers for predicting the therapeutic outcome of IDB.Methods: A prospective case series study was conducted, following time-series analysis moving averages models, with forty-one patients suffering from chronic discogenic lower back pain for more than six months. These patients subsequently received lumbar cool radiofrequency IDB and were enrolled in the study. Thirty-seven patients completed follow-up questionnaires at 1, 3, 6, and 12 months. The surgical outcomes were reported using visual analogue scale (VAS), Oswestry disability index (ODI), and the consumption of nonsteroidal anti-inflammatory drugs (NSAID). Furthermore, a univariate analysis was performed to identify prognostic factors associated with pain relief from age, gender, body mass index (BMI), and pre-operative lumbar magnetic resonance imaging reading.Results: Significant reductions were found in estimated VAS and ODI at the post-operative period at 1, 3, 6, and 12 months (P < 0.001). The NSAID dosage was significantly decreased at 3-month and 1-year follow-up (P < 0.05). No procedure-related complications were detected. The prognosis of IDB was not related to disc height, Pfirrmann grading or Modic endplate change. However, disc extrusions were associated with promising outcomes (VAS improvement ≥ 50%) on pain relief (P < 0.05).Conclusion: IDB is a good alternative choice for treating lumbar DDD. Patients with a painful extrusion lumbar disc may gain some benefits after receiving IDB following a period of failed conservative treatment. These findings may also add some references for physicians in the decision making when treating lumbar DDD. Lumbar degenerative disc disease (DDD) is a multifactorial progressive disease which may stem from genetic, metabolic, biomechanics, biochemical, environmental, and individual adverse risk factors Among all the interventional therapies, intradiscal biacuplasty  is one of the thermal annular procedures (TAPs), approved by the United States Food and Drug Administration in 2005 To our knowledge, there is no prognostic assessment of IDB according to the patients' characteristics and image findings. In the present prospective study, we analyzed clinical data findings based on 41 patients who received IDB by one surgeon in a single medical center, with the hope of providing a reference to physicians who want to perform this procedure.Figure . The study selection criteria were: 1) patients with a history of chronic lower back pain that is unresponsive to conservative care for a period longer than 6 months; 2) Age > 20 years; 3) disc height preservation > 50% compared to the adjacent disc; 4) presenting with axial back pain more frequently than leg pain, which was exacerbated by back flexion; 5) evidence of disc degeneration at ≤ three levels (Pfirrmann grade II-V) on L-MRI within 3 months; 6) the concordant degenerative disc showed positive reproducible pain provoked by intraoperative challenge discography. We diagnosed putatively painful discs according to several diagnostic properties detected on pre-operative L-MRI (herniated discs with characteristic degenerative changes) that were compatible with the patient's clinical signs indicating discogenic pain . We attempted intraoperative challenge discography on all suspected disc levels identified by both clinical and imaging findings. IDB treatment was applied to multiple disc levels simultaneously if reproducible pain appeared in multiple levels. By contrast, we abandoned the surgical treatment in cases where the challenge discography was not responsive. After excluding candidates with a previous history of tumors, unexplained bleeding/infection at the anticipated needle entry site, a history of opioid abuse, or existing herniated disc fragment in L-MRI, forty-one patients were enrolled as study subjects. Prior to entering the study, all patients had agreed and signed an informed consent form with a clear comprehension of the study details. All patients completed the 3-month follow-up outcome assessment questionnaire, whereas only 37 had completed the 12-month follow-up questionnaire except one lost follow-up at one year and 3 received a second surgery at 4, 8, and 9 months, respectively. Their follow-ups were terminated when they received the second surgery. Several long-term surveys were conducted via phone interview due to the geographical location. Drug consumption data were collected for 31 cases, taking into consideration the acceptance of prescribed nonsteroidal anti-inflammatory drugs (NSAID) at any follow-up period.The ethical approval of the present study was obtained from the research ethics committee of China Medical University Hospital (CMUH104-REC3-091). All methods were performed in accordance with the relevant guidelines and regulations. We started a prospective case series study following time-series analysis moving averages models from December 2017 to December 2020, a total of 58 IDB procedures with 74 discs were performed by one physician in the neurosurgical department of CMUH Prophylactic antibiotic was administered 30 minutes prior to the procedure. The patients were in a prone position with pillow support and ankle pads for comfort. Patients then received local anesthesia or intravenous sedation, including fentanyl, propofol or midazolam. Two transdiscal introducers were used through a posterolateral, oblique approach under fluoroscopic guidance to gain access to intervertebral discs. The provocative challenge discography was then performed to confirm whether pain was reproducible in the concordant disc level. Next, radiofrequency probes were positioned in the posterior 1/3 of the disc in the lateral C-arm view to access the proper positions over the annulus-nucleus junction of both probes. Our heating protocol increased the temperature to 50 °C gradually over a 15-minute period.At 1, 3, 6, and 12 months after surgery, patients in the outpatient clinic were asked to mark their pain level using a 10-cm visual analogue scale (VAS) Several variables were used in the present study to study their association to the improvement of pain relief. Age, gender, and body mass index (BMI) of patients were obtained from general clinical data. Patients with a BMI ≤ 25 were considered to be “normal” whereas a BMI > 25 was defined as “overweight.” Variables from spinal characteristics, including the maintained disc height (75-100% or 50-75% preservation), HIZ, endplate Modic (Type I and Type II), Pfirrmann grading (I-V), and types of disc herniation (protrusion and extrusion), were estimated from pre-operative L-MRI. Treated disc with a Pfirrmann grading I-III was regarded as “mild” degeneration whereas IV-V was deemed as “severe” degeneration. Changes in endplate Modic were defined as the existence of both types of changes.t-test. Analytic results with a P-value < 0.05 were regarded as statistically significant. All analyses were performed using GraphPad Prism 7 .One-way analysis of variance with Turkey HSD post-hoc comparisons was used to analyze the between-group difference of VAS, ODI, and NSAID use at different follow-up time. The effects of pre-operative types of disc herniation on VAS or ODI improvement were determined using Mann-Whitney U-test. Moreover, univariate analysis of general and image variables was done using the Chi-Square test where a VAS improvement equal to or over 50% was considered to be effective in treatment. The mean differences in VAS improvement of each variable were determined by Student's Figure 1 shows the detailed protocol for the patients' inclusion, exclusion, and data mining. Clinical data from 41 patients with an average age of 49.44 ± 10.78 (23-74 years old) were entered into the final evaluation (Table 1). The average follow-up period was 714.95 ± 243.05 days, during which no known serious adverse event occurred. Significant improvement was found on both VAS and ODI in response to IDB treatment . Post-operatively, the Mean VAS was changed from 7.49 ± 1.95 (baseline) to 3.70 ± 2.62, and to 2.44 ± 1.82 at 6 month. The reductions were stable and maintained at a 1-year follow-up. Similar effects were also be observed on the ODI score, which was changed from the baseline value of 41.02 ± 15.80 to 27.76 ± 17.28 at post-operation. Moreover, the value gradually reduced from the 3-month to the one-year follow-up (P < 0.01). Based on the findings, most patients  had at least 50% VAS improvement at the 6 month. However, a re-surgery rate of 7.3% (3/41) was observed with the follow-up period. One patient received percutaneous endoscopic lumbar discotomy at L4/5 8 months after two-level IDB treatment (L4/5 and L5/S1) due to persistent pain, and another patient received fusion surgery 4 months after IDB treatment in the same levels (L4/5) due to intolerable back pain. The use of NSAIDs was also significantly reduced at 3 and 6 months . The average free-to-NSAIDs-use period was 137.19 ± 144.95 days.Table 2). No association was found in basic information, including BMI, patient's age, and sex. For image characteristics, neither the presence of HIZ, Pfirrmann disc degeneration grading, the Modic changes in endplate, and disc height had no statistical significance. However, with respect to the characteristics of disc herniation, the result showed that disc protrusion was associated with significantly poor, substantial pain relief . Furthermore, we analyzed the improvement of pain and functional scales in detail characteristics based on the degree of extension of the herniated discs . There was no sequestrated disc in our study. In comparison to disc extrusion, disc protrusion within the annulus had less VAS and ODI improvement after IDB treatment (P < 0.05). The results indicated that for IDB more optimistic prognosis in pain relief can be found in patients with a disc extrusion (herniation beyond the annulus) in comparison with those with a disc protrusion.Univariate analysis of variables from general and image data was performed to determine critical factors for the prediction of positive response to IDB on substantial VAS improvement . The cost of IDB is not covered by National Health Insurance in Taiwan. However, in comparison to open surgical procedure which is paid by National Health Insurance, IDB is an outpatient percutaneous procedure that accesses minimally invasive and has a lower rate of adverse events According to the present data, we echo that IDB is one of the most effective TAPs for the treatment of DDD as most patients can achieve not only significant pain relief (33/40 patients with ≥ 50% VAS improvement) but also improved quality of life (31/40 patients with a ≥ 10-point decrease of ODI) within 6 months of post-surgery Table 2). We suppose that the therapeutic age limitation of IDB can be higher than nucleoplasty (NP) based on two possible reasons: (1) IDB mainly ablates sensitized nociceptors in lower temperature (50 °C) and longer duration (15 minutes), age is less of a factor. However, NP coblates the nucleus pulpous beyond 70 °C which intends to reduce the disc volume and intradiscal pressure, both of which are dependent on a younger age factor Table 2).According to the publications concerning TAPs, the criteria for patient enrollment is quite diverse, which may contribute to the lack of unified prognostic factors According to the enrollment of 41 patients in the present study, the majority of them (63.4%) are below 55 years old. However, the most common causes of lumbar DDD in youger patients result from overweight, trauma, overuse, or improper sports-related injuries Apart from patients' characteristics, it has yet to determine whether the pre-operative radiological characteristics affect the clinical outcomes of IDB. In the present study based on the pre-operative L-MRI, we show that the clinical outcomes can be affected by the characteristics (protrusion or extrusion) of the herniation of the intervertebral disc. Jae Chul Lee et al. also found similar results in conventional lumbar open discectomy Under our patient selection criteria, three patients required a second surgery after IDB treatment due to persistent back pain. One possible explanation is that discal nerve regeneration may result in the reconstruction of a nociceptive pathway that was previously blocked by IDB The study design has many limitations, such as the lack of randomization and a control group, a small number of cases, and a short follow-up period. In addition, the results still lack long-term evaluation of the prognostic factors. Another issue is that protruded discs have higher rate of spontaneous regression than extruded discs under conservative care, which may result in favorable outcomes Although there has not been an accurate method to predict the outcomes of IDB for painful lumbar disorder, signs on L-MRI such as disc extrusion may be an available marker for predicting a good prognosis.


To determine the clinical and laboratory differences between leukemic arthritis (LA) and juvenile idiopathic arthritis (JIA) at the onset of the disease.Patients under 16 years of age, both genders, who presented for the first time to the pediatric rheumatology service with a diagnosis of probable JIA, with arthritis and without peripheral blood blasts, in which the final diagnosis was acute lymphoblastic leukemia (ALL) or JIA. The clinical and laboratory characteristics of the patients were compared, chi-square and relative risk were used for categorical variables, and the Mann–Whitney U and T-test for the comparison of means between groups. A binary logistic regression model was developed to differentiate leukemic arthritis from JIA.A total of 76 patients, 14 with LA and 62 with JIA, were analyzed. The mean age at diagnosis was lower in the leukemic arthritis group, the female gender prevailed in the JIA group, and the time to onset of symptoms was lower in the leukemic arthritis group. Patients with leukemic arthritis showed increased pain intensity, fever, weight loss, nocturnal diaphoresis, lymph node enlargement, hepatosplenomegaly, and pain that did not improve with analgesic administration. Laboratory parameters with statistical significance were the presence of anemia, leukopenia, and neutropenia. The platelet count was significant but in a low normal value, compared to the JIA. A binary logistic regression model was developed to differentiate leukemic arthritis from JIA. The probability associated with the statistic (Chi-square) was 0.000, and the Cox and Snell R2 and Nagelkerke R2 values were 0.615 and 1, respectively. The developed model correctly classified 100% of the cases.The diagnosis of acute lymphoblastic leukemia should be ruled out in patients who present with arthritis and hematological alterations, mainly leukopenia and neutropenia, with joint pain disproportionate to the degree of arthritis, predominantly at night and that does not improve with the use of analgesics, fever, lymph nodes, and hepatosplenomegaly. Criteria are suggested to differentiate both diseases. Acute lymphoblastic leukemia (ALL) is the most common type of cancer in children, and juvenile idiopathic arthritis (JIA) is the most common chronic rheumatic disease in childhood. Most patients with leukemia present with symptoms of bone marrow failure , however; musculoskeletal manifestations occur in approximately 30% of cases, manifesting as bone pain, arthralgia, myalgia, limp or arthritis. Sometimes these joint symptoms are the only ones present, leading to a misdiagnosis of juvenile idiopathic arthritis, with the consequent use of steroids or disease-modifying drugs, which increase morbidity and mortality. We present a study that shows the clinical and laboratory differences between these 2 diseases, and we propose criteria to help the clinician to easily differentiate between them –4. (FAB) classification, and juvenile idiopathic arthritis according to the International League of Associations for Rheumatology (ILAR) criteria [Patients under 16 years of age, who initially presented to the pediatric rheumatology service of the General Hospital of the La Raza National Medical Center, from January 2013 to December 2022, with arthritis, who did not show blasts in peripheral blood, in whom the final diagnosis was juvenile idiopathic arthritis or acute lymphoblastic leukemia. Arthritis is defined as the presence of joint inflammation and effusion. The clinical manifestations evaluated were: age, gender, time of onset of symptoms, pain intensity, presence of nocturnal pain, remission with analgesics, fever, weight loss, nocturnal diaphoresis, lymph node enlargement, and hepatosplenomegaly. The laboratory variables evaluated were: hemoglobin, leukocytes, neutrophils, lymphocytes, platelets, erythrocyte sedimentation rate and C-reactive protein. The clinical and laboratory variables of both groups were compared. Leukemias were classified according to the French-American-British classification of acute lymphoblastic leukemiacriteria , 6.p < 0.05. A model was developed using binary logistic regression; the enter mode was used. The model's goodness of fit was verified using the Hosmer and Lemeshow's test, Cox and Snell's R2 and Nagelkerke's R2 were calculated.The SPSS 25 statistical software was used. The data were expressed in percentages for each area of analysis; chi-square and relative risk for qualitative variables, Mann–Whitney U test and T-test for the comparison of means between the groups. It was considered significant with a p = 0.084), the female gender predominated in the JIA group (p = 0.026). The pattern of arthritis in the group of patients with leukemia was polyarticular in 43% and oligoarticular in 50% (migratory in 71% of these). In the JIA group, the polyarticular pattern was the most frequent (85%)  and the pain intensity was 10 vs. 7 on the pain analogue scale (p = 0.0001), the presence of nocturnal pain that awakens the patient 79% vs 10% , pain remission with analgesics 0% vs 74% , fever 64% vs 6% , weight loss 86% vs 19% , nocturnal sweating 50% vs 0% , lymph nodes 86% vs 3% , hepato-splenomegaly 57% vs 3%  respectively. Anemia was observed in 42% vs 8% , leukopenia in 71% vs 2% , neutropenia 92% vs 0% n , thrombocytopenia in 43% vs 0% , mean hemoglobin value was 11.5 g/dL vs 13 g/dL (p = 0.009), leukocytes 3508 mm3 vs 9111 mm3 (p = 0.0001), neutrophils 695 mm3 vs 5143 mm3 (p = 0.0001), platelets 191,000 mm3 vs 378,000 mm3 (p = 0.0001) in leukemic arthritis and JIA group respectively. No difference was found in the values of lymphocytes, erythrocyte sedimentation rate and C-reactive protein  was 0.000, and the Cox and Snell R2 and Nagelkerke R2 values were 0.615 and 1, respectively. The developed model correctly classified 100% of the cases Tables  and 5.TaMusculoskeletal pain is a common symptom, affecting 10–20% of school-age children. Most of these complaints are benign in nature. However, some hematological diseases have been associated with rheumatic symptoms. These diseases can be benign  or malignant  [Leukemia is the most common childhood cancer (30–40% of cases) and acute lymphoblastic leukemia is the most common subtype (80%), with a peak incidence between 2–6 years of age. Most patients with leukemia present with pallor, fever, lymphadenopathy, visceromegaly, and a variety of hematologic abnormalities . However, one-third of pediatric patients with acute lymphoblastic leukemia initially present with symptoms associated with the musculoskeletal system [Articular manifestations can be explained by infiltration of the synovium, periosteum, or bone marrow by malignant cells. They can also be caused by the deposition of uric acid or immune complexes in the joint. A rare cause is hemarthrosis secondary to thrombocytopenia –4. The jBased solely on musculoskeletal pain, it is difficult to diagnose acute lymphoblastic leukemia, since musculoskeletal manifestations can mimic JIA, osteomyelitis, septic arthritis, or transient synovitis . CliniciOver the years, several reports have been made on the articular manifestations of hematological malignancies and their difference from JIA. Bone pain, arthralgia, limp, myalgia, true arthritis, night pain, pain out of proportion to clinical findings, elevated DHL, presence of peripheral blood blasts, leukocytosis, anemia, thrombocytopenia or low normal platelet count 150,000–250 000), neutropenia, or even normal leukocyte counts have been reported. In this type of patient in whom leukemia presents with musculoskeletal manifestations, a better prognosis with a longer survival has been observed when compared with those who do not present with musculoskeletal symptoms 50 000, n, 7–9.n = 53) had no blasts in peripheral blood at the time of evaluation. These patients were compared with those with JIA. The 3 strongest predictors of ALL were leukopenia (< 4000), low normal platelet count , and history of nocturnal pain. The combination of these values showed a sensitivity of 100% and a specificity of 85% for diagnosis of ALL. The number of joints affected in both groups was similar, and uric acid and LDH were not useful as predictors of ALL [In 2005, Jones conducted a multicenter study in 71 children diagnosed with acute lymphoblastic leukemia and 206 JIA patients to determine the factors that help differentiate between the two diseases. Of the patients with leukemia, 75% , non-articular bone pain , fever , neutrophil count less than 2000 , platelets < 300,000  were found to be significantly associated with the presence of leukemia. This article concludes with a decision tree in which if the patient presents with osteoarticular pain for at least 1 month, a bone marrow aspirate should be performed if accompanied by hepatomegaly, splenomegaly, or adenomegaly. If not accompanied by the latter, if associated with fever or increased inflammatory markers , plus non-articular bone pain and/or general symptoms , neutrophils < 2,000 or platelets < 300,000, a bone marrow aspirate should be performed to rule out ALL as the cause of the symptoms [Louvigne in 2020 conducted a study to identify early clinical and laboratory features that help distinguish between JIA and ALL. In a multicenter study, 49 patients with ALL and 98 with JIA were included. Oligoarthritis (43.9%) predominated in the JIA group, followed by polyarthritis (29.6%), arthritis-related enthesitis (18.4%), systemic arthritis (5.1%), and psoriatic arthritis (3.1%). Of the leukemia group, only one patient presented arthritis, the rest presented musculoskeletal pain. Neutrophils, eosinophils, basophils, monocytes, platelets, and hemoglobin were found to be low in patients with ALL. The presence of hepatomegaly, splenomegaly or adenomegaly (symptoms . In our The studies mentioned above show us that the clinical manifestations and complete blood count of both diseases are different. We only included patients with true arthritis in our study, which makes it different from previous studies in which most patients had musculoskeletal symptoms. This type of presentation of leukemia with true arthritis makes differential diagnosis more difficult for the pediatric rheumatologist, but with the proposed criteria, patients with suspected leukemia can be appropriately selected and bone marrow aspirate can be performed to establish a diagnosis and appropriate treatment. Prospective studies are needed to help validate our results.


Additionally, peak muscle strength increased independently of the device used, and again more rapidly in the fESWT group . In the stratified analysis for sex and for the type of ESWT, rESWT appears to be less effective in female participants in terms of mean muscle strength and PRTEE scores, without differences according to the type of device used. The rESWT group reported a higher rate of minor adverse events  compared to fESWT. Our data suggest that both fESWT and rESWT might be effective in improving LET symptoms, even if the higher rate of painful procedures were reported in patients treated with rESWT.Lateral elbow tendinopathy (LET) is characterized by pain, poor muscle strength of the wrist ex-tensors, and disability. Among the conservative rehabilitative approaches, focal as well as radial extracorporeal shock wave therapy (ESWT), are considered effective in LET management. The objective of this study was to compare the safety and effectiveness of focal (fESWT) and radial (rESWT) in terms of LET symptoms and the strength of wrist extensors, taking into account potential gender differences. This is a retrospective longitudinal cohort study of patients with LET treated with ESWT that had received a clinical and functional evaluation, including visuo-analogic scale (VAS), muscle strength using an electronic dynamometer during Cozen’s test, and the patient-rated tennis elbow evaluation (PRTEE) questionnaire. Follow-ups were carried out weekly in four visits after enrollment, and at 8 and 12 weeks. During the follow-ups, the VAS score decreased in both treatments, even if patients receiving fESWT reported early pain relief compared to those treated with rESWT (time for treatment  Tennis elbow, also known as lateral elbow tendinopathy (LET), is characterized by chronic degeneration at the origin of the extensor carpi radialis brevis muscle on the lateral epicondyle of the humerus . LET repp released from the treated region could explain the initial pain during and shortly after shockwave treatment of tendon insertion and subsequent lasting pain relief [Extracorporeal shock wave therapy (ESWT) is a noninvasive procedure considered safe and well tolerated by most of patients with LET , and then relief . Conflicn relief . Recentln relief . In a pin relief . We hypothesize that focal and radial ESWT act with different modalities in the healing processes, and that using different energy intensity or contact pressure on the tissues can induce procedural pain or side effects  that could influence the patients’ compliance. Therefore, the main objective of this study was to compare the effectiveness and safety of fESWT and rESWT in terms of pain relief, strength recovery, and side effects, respectively, taking into account the role of gender in this context.We performed a retrospective longitudinal cohort study including medical records of patients with painful LET referred to the Chiparo Physical Medicine and Rehabilitation outpatient in Lecce between January 2021 and December 2021. The study was planned at the Clinical Research Department of the Ludes Campus in Lugano (CH), and complies with the STROBE guidelines of the Consort Statement for the reporting of observational studies.To be eligible, patients had to be between 30 and 65 years old with elbow pain intensity on the visuo-analogic scale (VAS) of at least 50, and had to be negative upon screening for other sources of pain. The diagnosis of LET had to be confirmed by US evaluation showing structural inhomogeneity and altered tendon thickness. The study was developed following the Good Clinical Practice (GCP) guidelines. It was conducted within the ethical principles outlined in the Declaration of Helsinki, and with the procedures defined by the ISO 9001-2015 standards for “Research and experimentation”. Written informed consent to provide information included in personal medical records was obtained from all participants. No Ethics Committee was required, since this is a real-life  study that compares two medical devices that are routinely used in clinical practice.At baseline, all participants completed a sociodemographic questionnaire and anamnestic interview regarding the presence of comorbidities, medication intake, and potential risk factors for adverse drug reactions. Patients underwent functional and ultrasound examination of the elbow. Follow-ups were carried out weakly in four visits after enrollment (W1-W4), and at 8 and 12 weeks . In addition, patients completed the VAS  at every follow-up (Wbaseline-W12). However, at baseline, W4, W8, and W12 was assessed with the patient-rated tennis elbow evaluation (PRTEE) questionnaire , and a m2 and a frequency between 5 and 8 Hz, with 5 Hz for the first session and 8 Hz for the second and third sessions, respectively, were administered. The treatment was administered regularly, and titrated up to make sure it was always perceived as “strong but comfortable” during use. During the therapeutic procedure, patients were seated, and the affected elbow was positiond at 90° of flexion and in slight pronation. All impulses were transmitted in the epicondylar area, at the site of the insertion of the common extensor tendon. An ultrasound trasmission gel was placed between the applicator of ESWT and the skin.The focal group received three sessions of f-ESWT , administered by the same operator. For each single therapeutic session with f-ESWT, 1500 pulses emitted by focused shock wave generator (piezoclast-EMS ESWT) with a range of energy flux density between 0.12–0.18 mj/mmThe radial group received three sessions of r-ESWT , administered by the same operator. For each single therapeutic session with r-ESWT, 1500 pulses emitted by radial shock wave generator (Dolorclast Master-EMS) with a range of pressure between 2.0–2.5 Bar and a frequency between 08 and 13 Hz, 8 Hz for the first session and 13 Hz for the second and third sessions, respectively, were administered. The treatment was administered regularly, and titrated up to make sure it was always perceived as “strong but comfortable” during use. During the therapeutic procedure, patients were seated, and the affected elbow was positiond at 90° of flexion and in slight pronation. All impulses were transmitted in the epicondylar area, at the site of the insertion of the common extensor tendon. An ultrasound trasmission gel was placed between the applicator of ESWT and the skin.In subjects treated with ESWT, in the short-medium term (12 weeks), the reduction in the pain reported is evaluated to be 70% of the initial level . We hypop-value for differences was considered statistically significant at a value less than or equal to 0.05.Data were reported as mean ± standard error (S.E.) for continuous variables, and as an absolute number and percentage for dichotomous variables; differences between groups were assessed with analysis of variance and Chi-square test, respectively. All analyses were conducted with an intention to treat analysis. To assess variations in VAS score, pick muscle torque, mean muscle strength, PREE total score, self-reported pain subscale and specific and non-specific disability score, linear mixed models were applied . The advp-value = 0.66). Almost 40% of the patients were white-collar workers, and 22 (26.2%) practiced sport  were females, with a mean age of 46.7 ± 8.4 years, and 50 (59.5%) reported pain at the right elbow, without statistically significant differences between study groups. A total of 24 (57.1%) were enrolled in the rESWT compared to 26 (61.9%) of the fESWT . When the interaction between time and treatment is considered in the model, a multiplicative effect could be demonstrated, favoring fESWT . With the interaction term in the model, the ρ decreased from 0.84 to 0.38, meaning that a smaller fraction of the total variation is influenced from the higher starting level of pain. In p-value = 0.002), W3 , and W2  compared to W12. Almost all the differences between sex could be attributed to rESWT treatment, since no differences could be demonstrated in the VAS scores between sex in the fESWT group.In In both treatment groups, muscle pick torque increased over time; an estimated 23% (ICC) of the total variation in the strength is attributable to differences between patients , Model Ap-value < 0.001, p < 0.001), and a multiplicative effect can be also demonstrated . Muscle mean strength increased over time in both groups, but no multiplicative effect for the interaction between groups and time could be reported; moreover, no statistically significant differences could be seen between sex . On averp-value < 0.001) and to W12 . At W4, the ES-R group reported higher PRTEE scores  compared to ES-F; those differences were no more statistically significant at W8 and W12. Excluding from the analysis those patients that interrupted the treatment, the female sex at W4  and W8  responded less to the ES-R approach in their PRTEE total scores . Among those 15 patients, ten out of the 84 enrolled dropped out and shifted towards another therapeutical rehab approach. Among them, six (14.3%) were in the rESWT group, and four (9.5%) were in the fESWT treatment; three were males, and seven (15.2%) were females .Fifteen patients out of 84 (17.9%) developed an adverse event ; of those, 11 (26.2%) were in the rESWT group and four in the fESWT group , these interventions share the ability to promote tissue healing, to induce the release analgesic mediators and to relieve pain ,16. The Therefore, no clear evidence of superiority of one of the two type of ESWT could be derived from analysis of the literature . In our The rationale for explaining better results obtained through fESWT could be that fESWT is concentrated on a restricted area and can penetrate deeper in the body com-pared to rESWT . MoreoveEven if the most frequent intra-intervention complaint was pain in the shock wave application area, other adverse effects of ESWT may include transient skin reddening, small areas of subcutaneous extravasation resulting from small vessel injury, bruises, local swelling and numbness of the area . LookingWhile the two ESWT approaches were shown to be effective in pain control and strength recovery, conversely, focal and radial ESWT seemed less effective in improving the PRTEE subscale than the total score. From our point of view, the computational way that the PRTEE subscales and total score are calculated could influence the low variability of the scale, linking almost all of the variance to the “between-subjects” level . This coThe most important limitation to be considered in our work is the study design, as previously stated. Additional observational retrospective analysis could help to elucidate scientific questions, especially if data were drawn from a real-life clinical approach. Moreover, a sham control group or exercise-only treatment group could be helpful in disentangling the question of the effectiveness of the ESWT in LET treatment. However, the results of previous studies showed that either f-ESWT or r-ESWT had an advantage over a placebo in terms of pain relief and knee function improvement in those patients . AnotherKeeping in mind the limitations due to the observational retrospective design of our study and the lack of sham control group, ESWT seems to be a valid alternative to the classical exercise approach in the treatment of pain, disability, and muscle impairment in LET; this is the case even if in the female sex, rESWT seems to be less effective and requires more time to achieve pain relief and functional recovery.