To assess inappropriate analgesic use (IAU) by comparison of STOPP/START Version-2 and Beers 2019 criteria.This is a cross-sectional study of 331 elderly patients admitted to family medicine clinics at a tertiary hospital between February and July 2018. Data were collected from face-to-face surveys, including informed patient consent and electronic drug monitoring databases.The presence of IAU by STOPP version2 was higher than the Beers criteria  with a moderate agreement (Kappa= 0.458). The number of drugs and pain score were predictors of IAU. The most commonly caused IAU was diclofenac, although naproxen was the most used analgesic. Almost 39% of diclofenac use, 18.5% of naproxen use, and 33% of etodolac use were IAU. Most commonly, IAU reasons were; (i) NSAID use in hearth failure (Beers) (ii) NSAID use with an antiplatelet agent(s) without PPI (STOPP).The difference between criteria in terms of IAU was significant in favor of STOPP V2. When a pain appeared in the knee or back through aging, people begin to understand how old they are. Another way to define aging maybe by looking at the numbers of drug boxes. Elderly patients having a history of multiple drug use and suffering from pain are a problem for doctors because of the need for painkillers.The meaning of pain will differ among patients depending on how pain affects their lives.The Beers Criteria identifies potentially inappropriate medications for better therapeutic regimens. As a result of the need to alert healthcare providers to the potential harms of specific medications, Beers Criteria was published in 1991 and recently updated in 2019.5STOPP ( Screening Tool of Older Person’s Prescription ) Version-2 /START (Screening Tool to Alert doctor to Right Treatment) criteria have been expanded and updated in 2015 recently to minimize inappropriate prescribing in elderly patients. These criteria are based on an up-to-date literature review and consensus validation among a European panel of experts.6Both criteria were selected because they are the most used and cited in studies on inappropriate drug prescribing in elderly patients.We hypothesized; (i) Patients 65 years and older do not use rational analgesics (ii) There might be significant differences in the detection of IAU according to Beers and STOPP criteria (iii) There might be low awareness of painkillers and side effects, as well as the over or underuse of analgesics in pain treatment, especially about opioid group analgesics.We aimed; (i) To assess IAU and related factors in elderly adults compared with Beers and STOPP criteria (ii) To search the presence of pain and the awareness of NSAID and opioid analgesics.The study was performed by a cross-sectional evaluation of 331 older patients (≥aged 65 years) who were admitted to the family medicine outpatient clinics of a tertiary training and research hospital between February and July 2018. Data were collected from face-to-face surveys, including informed patient consent and electronic drug monitoring databases. Ethical permission to conduct this study was obtained from the Local Ethics Committee . The study was conducted in compliance with the Declaration of Helsinki.Patients who were prescribed analgesic by the Algology clinic for chronic pain management, patients diagnosed with advanced-stage dementia or Alzheimer’s disease, and patients receiving active cancer treatment were excluded. All medications that participants had taken within the last two weeks were taken into consideration.Beers’ 2015 criteria were available when the study was started, and the 2019 update was published during the analysis of the study. Therefore we examined the IAU using the American Geriatric Society’s Beers Criteria 2019 and STOPP /START Version-2 criteria. We assessed criteria for i) Appropriateness of analgesic drug use ii) Another drug- Analgesic drug interaction iii) Analgesic drug- Disease interaction iv) Therapeutic duplications of analgesic drugs v) Underuse of analgesic drugs vi) Analgesic use with cautionThe pain was measured using the visual analog scale for pain (VAS). The pain was defined according to the World Health Organization (WHO) scale, which was a 0–10 numeric rating scale.Descriptive statistics were used to measure the frequency, mean, and standard deviation of all variables. Covariates were analyzed using the Mann-Whitney U test and the Chi-square test; correlations were done by the Spearman test; furthermore, logistic regression analyses were used to evaluate the risk factors affecting IAU. According to Beers and STOPP criteria, IAU numbers were compared with the Wilcoxon test. Agreement in between Beers 2019 and STOPP Version-2 was checked with the Kappa test. Data were analyzed with the NCSS 10  program.Out of 331 patients aged between 65 and 97 years , 176 (53.2%) were female and 155 (46.8%) were male. The mean number of chronic diseases was 3.30±1.51 (Median = 3). The distribution of chronic diseases was hypertension 22.7% (n: 248), diabetes 11.3% (n: 124), coronary artery disease 7.9% (n: 86), chronic renal failure 7.5% (n: 82), respectively. The mean number of drug consumption was 6,87±2.76 (Maximum = 15), and the mean number of the analgesic drug was 0.66±0.41 (Maximum = 3). Polypharmacy was defined as using greater than or equal to five medications, and the prevalence of polypharmacy among our patients was 87.3%.The association of IAU with demographic data and pain medication for Beers 2019 and STOPP/START criteria Version-2 is shown in The presence of pain in patients suffering from pain in the last three months was 90% (n:298). Pain prevalence in women was higher than men, significantly (p:0.014), but there was no gender difference in pain medication use (p:0.434). 25.4% of participants described their intensity of pain as mild pain , 65.9% had moderate pain , and 8.8% had severe pain . 37.2% of cases were recently diagnosed as chronic pain. IAU was higher in patients with chronic pain than those without. The most painful region was lower extremity (knee) (26.9%), but the most frequently used IAU region was lower back (20.1%). The presence of headache, pain in the upper back, and pain in other regions were 21.8%, 7.9%, and 12.4%, respectively. There was a difference between painful regions for IAU . Participants had a 35.6% of pain every day, 14.8% of pain once/twice a week, 21.1% of pain once/twice a month, 18.4% of pain once/twice a year while 10% of all had never pain complaint.About 51.1% of participants were taking non-opioid analgesics. The prevalence of NSAID use in those taking nonopioids was 8.2% for naproxen, 6.9% for diclofenac, and 23.9% for paracetamol. The most commonly used analgesic drug was naproxen (8.2%), while the most common cause of IAU was diclofenac (2.7%). 39% of diclofenac use, 18.5% of naproxen use, and 33% of etodolac use were IAU. Only paracetamol use was found to be 23.9%, while both paracetamol and NSAID users were 22.7%. The frequency of multiple NSAID molecules’ use was 13%. The prevalence of any NSAID use was 33.2% of all. 20.2% (n: 67) of participants were using only one type of NSAID, 10.3% (n: 34) using two types of NSAIDs and 2.7% (n: 9) three types of NSAIDs.IAU prevalence detected by STOPP Version-2 was higher than that of the Beers 2019 criteria  with a moderate agreement in between (kappa=0.458). IAU was found to be 15.4% according to START criteria. The underuse of analgesics was higher than inappropriate use. IAU presence determined by STOPP criteria but not determined according to Beers criteria was 10.3% of cases.Most commonly IAU reason for Beers criteria was; ‘’Use with caution in patients with heart failure who are asymptomatic; avoid in patients with symptomatic heart failure: NSAIDs and COX-2 inhibitors ’’. Accordingly, the most common opposed STOPP criteria for IAU was ‘’ C11. NSAID with concurrent antiplatelet agent(s) without PPI prophylaxis (increased risk of peptic ulcer disease) ‘ whereas it was ‘’H1- High-potency opioids in moderate-severe pain, where paracetamol, NSAIDs or low-potency opioids are not appropriate to the pain severity or have been ineffective’’  with the START criteria as underused.21.8% of the participants stated that they had side effects related to painkillers , as seen in 40.2% of the patients had no awareness about painkillers and side effects. Patients had been informed; 44.4% from doctors/health professionals, 11.2% from acquaintances, 3% from pharmacists, 1.2% from multi-media.number of drugs ; number of disease ; pain score . There was no significant difference between IAU and age or number of diseases (p>0.05).Weak and medium correlations were found between the IAU and Factors associated with IAU were analyzed for the Beers, STOPP, and START criteria. In the analysis number of chronic diseases is not a significant predictor for all criteria. The risk factors associated with IAU emerged as a higher drug number and a higher pain score. In this present study, elderly adults who applied to a tertiary hospital were evaluated for rational analgesic use. The presence of inappropriate NSAID use was found as high as the presence of inadequate use of opioids. Half of the elderly patients in our study use at least one analgesic, and at least one out of three patients use NSAIDs. The knowledge about analgesics was not enough in patients, although analgesics might have many side effects on cardiovascular, GIS, and other systems in geriatric physiology.The presence of NSAID use in order were reported 20.3% from Germany , 25% from America (African Americans aged 65 and older from 16 churches located in south Los Angeles), 28% from Serbia .The IAU prevalence was detected as 14.5% by Beers 2019 criteria. Among patients admitted to a health center, the IAU prevalence varied widely being as low as 2.5% as in tertiary care teaching centres by “Beers 2012” from India, 7.1% from France in geriatric units in 28 hospitals by “Delphi process containing Beers 2015”, 9.3% from Turkey in a geriatric clinic of a university hospital by “Beers 2012” and as high as 43.04% among older Koreans by “Beers 2012” from Korea.18Non-steroid anti-inflammatory drugs (NSAIDs) are largely used in pain management, even for long periods (months or years). While gastrointestinal side effects such as bleedings from peptic ulcers are known, the cardiovascular side effects have received much less attention. A warning (Nota 66) on the careful prescription of NSAIDs in patients with overt heart disease, such as coronary artery disease and heart failure, was published by the Italian Drug Agency a few years ago.The IAU prevalence was defined as 19.6% by STOPP criteria Version-2. A study from the Netherlands  gathered in the GPs’ database of the Academic Medical Center of Amsterdam) suggested that of patients with heart failure, 11.8% received ≥1 prescription for NSAIDs in 1 year, which is contraindicated.The underuse of analgesic was detected as 15.4% by START criteria. That means opiate use is inadequate depending on WHO  analgesic ladder. A study from the Netherlands using STOPP/START reported 12.9% a prescription for opiatesA recent review of deaths from opioids concluded that the burden of opioid overdose in elderly adults requires special attention, noting the largest relative increase in opioids occurred in persons 55 to 64 (754% increase from 0.2% to 1.7%) and 65 years and older (635% increase from 0.01% to 0.07%) and the absolute number of deaths in this group is moderate. In 2016, 18.4% (7762 of 42 245) of all opioid-related deaths in the United States occurred among those aged 55 years and older.23On the other hand, Beers’ list has two significant limitations, i.e., the focus on the American drug market and the restriction to potentially inappropriate medications. Pain medication list in Beers criteria did not include our patients using dexketoprofen, flurbiprofen, sulfasalazine, acemetacin, etofenamate, methimazole. Therefore in our opinion, Beers criteria are not truly reflecting the prevalence of inappropriate use of analgesics in Turkey.We compared the success of Beers 2019 against STOPP Version-2 and found that the last updates on Beers criteria were not as good as STOPP Version-2 criteria yet.Our study was performed cross-sectionally and evaluated five months. The results of cross-sectional studies could, therefore, be biased due to seasonal or epidemical variations in medication use or the occurrence of pain complaints. Another limitation of our study was that OTC (over the counter) products might be procured without a prescription and the records of these drugs cannot be tracked from the monitoring systems, and records could not be included in the study.We conclude that STOPP screening criteria were more helpful than Beers criteria to reduce the negative consequences of analgesics, because of the significant difference was found between the two tests in terms of IAU cases. Inappropriate diclofenac use in the elderly patient was the well-marked finding of this present study, although NSAIDs have the cardiovascular or GIS side effects. The number of drug consumption and pain score (VAS) was predictors for IAU. The physician who may approach the elderly patient holistically and make the conventional follow-up of all treatments is the family physician in the first step. So, primary care is indispensable to control rational analgesic use under specific criteria in cases of pain management and polypharmacy.MMB: Did data collection, manuscript writing, editing, statistical analysis.OB: Did data collection, editing of manuscript, review and final approval of the manuscript.


The incidence of laparoscopy-related shoulder pain reaches 90% in women. We evaluated the effect of lidocaine patch 5% on the shoulder pain after laparoscopic cholecystectomy (LC) in female patients. Total 63 female patients were randomly allocated to patch group (n = 31) and control group (n = 32). Patch group received lidocaine patch 5% and dressing retention tape on both shoulder, and control group received only dressing retention tape. Abdominal and shoulder pains were evaluated with rating on numeric rating scale (0 = no pain and 10 = the worst pain) at baseline and at 30 min, 6 h, 24 h, and 48 h after surgery. There were no significant differences in patient characteristics and operation details. The overall incidence of shoulder pain was significantly lower in patch group than in control group . The severity of shoulder pain also was significantly reduced in patch group compared to control group at 24 h and 48 h after surgery . Complications related to lidocaine patch were not found except nausea. Lidocaine patch 5% reduced the incidence and severity of postoperative shoulder pain in female patients undergoing LC without complications. Although LC is considered as a less painful procedure, patients may experience shoulder pain after undergoing LC. Shoulder pain after surgery occurs rarely in open surgery, but its incidence rises to 30–60% in general laparoscopic surgery, reaching 90% in women4. Some patients unexpectedly may experience severe pain in laparoscopic surgery than in aggressive, major surgeries5. However, laparoscopy-related shoulder pain is poorly responsive to analgesics4. Therefore, the efforts to prevent the laparoscopy-related shoulder pain are essential.Laparoscopic cholecystectomy (LC) has become a standard treatment for gall bladder disease because of advantages such as smaller incision, shorter hospital stays and faster recovery compared with open cholecystectomy2 gas6. Clinically, diaphragmatic irritation manifests as referred pain in the shoulder arising from the phrenic nerve7. Interventions to reduce shoulder pain after LC aim to minimize diaphragmatic irritation through low-pressure pneumoperitoneum8, intraperitoneal instillation of analgesics9, drain suction10, active gas aspiration11 or phrenic nerve block12. However, local anesthesia applied to the area of referred pain, and not initial area, has also been shown to be effective in reducing referred pain in the tibialis muscle13; further, trigger point injection or a eutectic mixture of local anesthetics (EMLA) cream applied to the shoulders, not the diaphragm, significantly reduced shoulder pain after laparoscopic hysterectomy14.Although the mechanism has not been fully clarified, laparoscopy-related shoulder pain is generally considered to develop due to diaphragmatic irritations from direct injury, stretching, or CO15. In a randomized controlled study of myofascial pain syndrome, lidocaine patch 5% decreased the symptoms of pain and the sensation of the skin as effectively as trigger point injection16. We hypothesized that application of lidocaine patch 5% to the shoulder could also reduce the severity of shoulder pain after LC.Lidocaine patch 5% is a topical analgesic that interrupts pain signals in peripheral nociceptors with minimal systemic absorption and few adverse effectsThe aim of this study was to evaluate the analgesic effect of lidocaine patch 5% on shoulder pain after LC in female patients.This randomized, double-blinded, prospective, parallel-group study was conducted with patients undergoing LC at the Ajou University Health System between February 2017 and September 2017. The Ajou Hospital Institutional Review Board affiliated to Ajou University School of Medicine (protocol number: AJIRB-MED-CT4-16-076) approved the study protocol . This study was conducted in proportion to relevant guidelines and regulations. After obtaining written informed consent from all participants, female patients with American Society of Anesthesiologists (ASA) physical status I, II or III aged 19–85 years, were included. LC included both elective and emergence surgeries performed in the day time (8:00–17:00). Exclusion criteria were as follows: histories of trauma, infection, surgery, or chronic pain involving the shoulders, hypersensitivity to local anesthetics, chronic abuse of opioids, impaired liver or renal dysfunction, or denial to participate in this study.http://www.random.org) at 1:1 ratio by J.E.K.: the patch group (n = 32) and the control group (n = 32). Assigned group was concealed in a sealed, opaque envelope. Immediately before anesthesia induction, the envelope was opened by an independent investigator who performed all interventions but was not participated in outcome assessment. The anesthesia provider, patients, and preoperative and postoperative outcome assessors did not know the assigned group throughout the study period.Participants (n = 64) were randomized to one of two groups by randomization generator  were applied to both shoulders of patients in the patch group; then, the lidocaine patches were covered with dressing retention tape . In the control group, only dressing retention tape  was applied, also to both shoulders. The patients’ shoulders were covered with clothes; thus, the outcome assessors could not see it. For anesthesia induction, intravenous (IV) propofol 2 mg/kg and remifentanil 0.3 μg/kg were started and rocuronium 0.8 mg/kg was followed. After endotracheal intubation, mechanical ventilation was initiated. For maintenance of anesthesia, remifentanil was infused at a rate of 0.05–0.10 μg/kg/min, and sevoflurane 2–2.5% was used within a range of bispectral index score 40–60. In case of mean arterial pressure (MAP) < 60 mmHg or heart rate (HR) < 40 beats/min, IV ephedrine 4 mg or atropine 0.5 mg was administered, respectively. Approximately 10 min prior to the end of surgery, IV propacetamol 1 g was administered for postoperative analgesia. At the end of surgery, sevoflurane were discontinued, and the fresh gas flow was increased to 5 L/min. To reverse residual neuromuscular blockade, IV neostigmine 50 μg/kg plus glycopyrrolate 10 μg/kg were injected after confirming the train-of-four count > 2 using a nerve stimulator. After confirming adequate tidal volume, patients were extubated with maintaining the remifentanil infusion of 0.05 μg/kg/min to prevent the emergence cough. Then, the patients were transferred to a post-anesthesia care unit (PACU).2 gas was inflated through infraumbilical Veress needle. Abdominal insufflation pressure was set at 12 mmHg. Drain was not inserted, and local anesthetics were not injected at peritoneum or port site.All procedures were carried out by two skilled surgeons with same method. LC were performed through three abdominal ports . COThe primary outcome of this study was the severity of shoulder pain after surgery. Preoperative variables included demographics, ASA physical status, and diagnosis. Intraoperative variables included anesthesia time, operation time, and amounts of crystalloid and bleeding. Hemodynamic data such as HR and MAP were collected at five time points: at baseline, at pneumoperitoneum, at 20 min and 30 min after pneumoperitoneum, and at the end of surgery. Pain included the abdominal pain, and overall, right, and left shoulder pains. The incidence of shoulder pain was evaluated based on the overall value of shoulder pain and defined as the number of patients who had a pain score that was higher than the value at baseline. “> abdominal pain” was defined as the number of patients who had worse shoulder pain compared with abdominal pain during the 48 h following surgery. “Alleviated pain” was defined as the number of patients who had less shoulder pain compared to value at baseline. The severity of pain was quantified on a numeric rating scale (NRS) ranging from 0 to 10 (0 = no pain and 10 = the worst pain) at five time points: at baseline, and at 30 min, 6 h, 24 h, and 48 h after surgery. The pain score at 48 h after surgery was investigated by phone call with the patient. Nausea was graded into four . IV ramosetron 0.3 mg was administered to with vomiting or nausea grade ≥ 3 or 4. The lidocaine patches and/or dressing retention tape were removed by the ward’s attending nurse at 12 h following surgery. Complications related to lidocaine patch 5%  were evaluated by the ward’s attending nurse at ward until discharge from the hospital.On arrival to the PACU, IV fentanyl 1 μg/kg was administered as a rescue analgesic in patients reporting an NRS ≥ 5. At the ward, IV ketorolac 30 mg was administered at 8 h intervals on the day of surgery. In addition, IV nefopam 20 mg was administered as a rescue analgesic in patients reporting an NRS ≥ 5. At the postoperative day 1, the patient discharged with prescription drug, which was consist of oral acetaminophen/tramadol 325/37.5 mg at three times a day.17. Considering that a mean difference of 1.2 in pain score was significant18, 29 participants were required in each group for a type I error of 5% and a power of 90%. Considering a 10% dropout rate, a total of 64 patients (32 per group) were required.To calculate the sample size, we focused on the severity of shoulder pain after surgery. In a previous study, the pain score of shoulder pain after LC was 4.43 ± 1.4Data are shown as mean ± standard deviation (or standard error), median (interquartile range), or number of patients (proportion). Normality of distribution was assessed with the Kolmogorov–Smirnov test. Parametric and nonparametric data were analyzed using Student’s t-test and the Mann–Whitney test, respectively. Categorical data were analyzed using the chi-square test or Fisher’s exact test. Repeated measured data were analyzed using the linear mixed model. When the interaction was statistically significant, the adjusted P value was obtained with Bonferroni correction. P < 0.05 was considered statistically significant. SPSS for Windows  was used for statistical analyses.Of the 64 patients included in this study between February 2017 and September 2017, one patient in the patch group dropped out due to persisting intolerable abdominal pain; finally, the data of 63 patients were analyzed  and was significantly lower in the patch group than in the control group at 24 h and 48 h after surgery . Right shoulder pain was lower in the patch group at 24 h after surgery ; consequently, the incidence and severity of shoulder pain after LC were reduced significantly.A “pre-local hyper-excitability theory” has been proposed, in which stimuli in the initial area cause the hyper-excitation of the connective nerve between the referred area and initial area, consequently inducing the increased sensitivity of the referred area25. Each patch contains 700 mg of lidocaine in aqueous base, but only 2–3% of the dose is absorbed; the peak plasma level is 0.13 μg/mL , thus showing minimal adverse effects26. In a previous study, application of an EMLA cream on the shoulders reduced laparoscopy-related shoulder pain to an NRS score of < 114, which was more effective than the lidocaine patch 5% used in present study . One of differences between the EMLA cream and the lidocaine patch is that EMLA produces local anesthesia by blocking large sensory fibers15 and the lidocaine patch exerts an analgesic effect by blocking the small sensory fibers without causing local anesthesia. Thus, the skin under the lidocaine patch has a normal sensation15. Despite the low analgesia potency, the lidocaine patch might be better for surgical patients than the EMLA cream due to the lack of numbness and occlusive dressing.Lidocaine patch 5% is a skin patch approved for the treatment of post-herpetic neuralgia. It is also used for localized and painful conditions such as vascular access, pain caused by trauma fracture, wound pain after surgery, and arthritis27. In addition, the present study only included female patients who have a lower pain threshold than male28. This is interesting finding that shoulder intervention showed more effective analgesia than diaphragmatic intervention during LC, because referred pain has been known to be mainly associated with central components  and not with peripheral components (referred area).The peak shoulder pain score in this study was 1.3 at 24 h after surgery in the patch group. This was lower than the scores ranging from 1.9 to 4.2 in studies focusing on lessening diaphragmatic irritation during LC15. In patients with myofascial pain syndrome, the effect of lidocaine patch 5% applied to three focal sites throughout the body for 4 days was superior to that of a placebo patch until day 9 after the beginning of treatment16. Similarly, in an area limited to the upper trapezius, a lidocaine patch applied for 7 days also relieved pain more effectively than a placebo patch for a period of 2 weeks29. There are two possible explanations for the long analgesic period of the lidocaine patch. First, after long-term application, lidocaine patch 5% decreases epidermal nerve fiber density without affecting pressure pain and threshold for heat- and cold-induced pain in the skin of healthy volunteers30. Second, central sensitization might play a role in persistent complaints in patients with shoulder pain31, although being poorly investigated. In the present study, the antinociceptive effect of lidocaine patch 5% that was initiated before the pneumoperitoneum might inhibit the central sensitization of the shoulder to some degree.In the present study, shoulder pain after LC was reduced until 48 h after surgery despite the application of the lidocaine patch during the first 12 h. Lidocaine patch 5% has a half-life of 6–8 h2. During laparoscopic hysterectomy, right shoulder pain was more severe than left shoulder pain32. In contrast, Schoeffler et al. reported that more severe shoulder tip pain is noted in the left side in reference with protection of the right side of the diaphragm through the liver33. Further research is required to evaluate which side is more affected.Right and left shoulder pain did not differ in the patch and control groups in present study. Shoulder pain after LC is generally more frequent in the right side34.This study has several limitations. First, the sample size might be small when considering the simple intervention. Further studies are needed to verify our findings in a larger sample size. Second, shoulder pain scores were not evaluated by dividing separately during rest and movement. Third, when patients requested rescue analgesics, the main site of complaint was not evaluated. Fourth, more-than-mild pain (NRS ≥ 4) has considerable clinical significance. Regretfully, the number of patients with shoulder pain of NRS ≥ 4 was similar in this study . Fifth, at the time of patch removal by a nurse, the patient might have not remained blinded. Shame patches may be needed for complete blinding. Sixth, longer follow-up time of patients would be needed, because post-laparoscopic pneumoperitoneum was detected on upright chest radiographs in patients undergoing LC within the first week after surgeryIn conclusion, lidocaine patch 5% reduced the incidence and severity of postoperative shoulder pain in female patients undergoing LC. Application of lidocaine patch 5% on the shoulder can be a simple, non-invasive, and effective analgesic method without adverse effects.


Over the past few months, in order to mitigate the spread of COVID-19, in-person access to physicians was limited and predominantly moved to telemedicine. While telemedicine has been beneficial in maintaining contact with patients and continuing therapy, due to an inability to perform a physical exam, it did delay and has created lag in proper diagnosis and treatment. Furthermore, diagnostic imaging such as x-rays, CT scans, MRI scans all have had to be deferred, which while certainly not required to make the diagnosis can be beneficial for diagnostic and therapeutic purposes. Additionally, due to deferment of elective cases, patients who were currently awaiting to undergo extensive surgery such as laminectomy, discectomy, hip arthroplasty or total knee arthroplasty have had their surgeries delayed and are having their pain managed with medicines, in some cases narcotics. Interventional pain procedures that needed multiple trials such as medial branch blocks, spinal cord stimulator trials have also been hindered further postponing the subsequent therapeutic procedures like radiofrequency ablations and spinal cord stimulator implants.Due to the on-going pandemic, other sources of stressors and pain have amplified ultimately worsening chronic pain. For instance, physical therapy (PT) programs, which are an integral part of multimodal chronic pain management, have been halted due the COVID-19 pandemic . NumerouOn 19 March 2020 governor Greg Abbott approved the Texas Medical Board to temporarily suspend Title 22, Chapter 174.5 (e2A) of the Texas Administrative Code . This waCurrently, as different states start to reopen and as we resume elective procedures, we have been noticing a backlog of patients to be seen that are both established and new consults. Patients have had their appointments rescheduled and are unable to be seen until weeks or months later. Resumption of elective procedures still means some patients may have to wait weeks to months for their procedures. Moreover, patients are still apprehensive about proceeding with elective procedures, and rightfully so, at the risk of being exposed to COVID-19. Additionally, many patients who initially had medical insurance lost their coverage as they were either furloughed or laid off by their job. This has already hindered and could further delay interventional or therapeutic treatment plans. Furthermore, with new rules being implemented in hospitals, surgery centers and clinics to avoid viral spread, this has and will result in increased turn-over time, limiting the number of procedures physicians can safely do in a day. This ultimately would cause patients to receive interventions at a later time which could prolong their chronic pain symptoms, ultimately putting pain physicians at a precarious position of managing pain with opioids.However, as discussed above, there is a silver lining from this pandemic, and that is the implementation of telemedicine . As physThe COVID-19 pandemic has impacted everyone around the world including all sectors of the economy, all businesses, healthcare industry, physicians and patients alike. With the deferment in elective procedures to contain the spread of COVID-19, limited access to multimodal therapeutic modalities such as PT, psychologist and psychiatrist appointments and with the added psychosocial emotional stressors from the pandemic, economic and financial insecurities, the potential for worsened chronic pain symptoms are very high. And with limited availability of multimodal therapeutic alternatives employed by pain physicians, these physicians are having to prescribe pain medications until the patient is able to get their treatment. Chronic pain physicians are having to walk the fine line of balancing the previously on-going opioid crisis and now this pandemic in managing the pain with the limited resources available. The key moving forward is trying to closely follow these patients, wean opioids and get them back on their pre-COVID-19 treatment plan as other multimodal therapeutic options open up.


Mirogabalin, which is approved for the treatment of peripheral neuropathic pain in Japan, is a ligand for the α2δ subunit of voltage-gated calcium channels. Both pregabalin and mirogabalin act as nonselective ligands at the α2δ-1 and α2δ-2 subunits. Mirogabalin has a unique binding profile and long duration of action. Pregabalin has been reported to produce intolerable adverse effects in some patients. This study investigated outcomes associated with mirogabalin administration in patients with peripheral neuropathic pain who ceased treatment with pregabalin.We retrospectively assessed peripheral neuropathic pain using the neuropathic pain screening questionnaire (NeP score) in 187 patients  who were treated with mirogabalin. All patients had switched from pregabalin to mirogabalin due to lack of efficacy or adverse events. Differences in the treatment course  scores) were compared using one-way analysis of variance with Bonferroni post hoc tests.The mean age of the patients was 72.3 years , and the mean duration of disease was 37 months . After treatment with mirogabalin for 1 week, NRS scores significantly decreased compared with baseline and continued to decrease over time. After 8 weeks, NRS scores improved by ≥ 30% from baseline in 113 patients (69.3%). Twenty-four patients (12.8%) stopped mirogabalin treatment due to adverse events. Somnolence (26.7%), dizziness (12.3%), edema (5.9%), and weight gain (0.5%) were noted as adverse events of mirogabalin.The results of this investigation indicate that mirogabalin is safe and effective for reducing peripheral neuropathic pain. The International Association for the Study of Pain defined neuropathic pain as “pain caused by a lesion or disease of the somatosensory nervous system” . NeuropaPregabalin is a ligand for the α2δ subunit of voltage-sensitive calcium channels and is recommended as the first-line drug for neuropathic pain in guidelines around the world . It decrMirogabalin, which is a potent and specific ligand for the α2δ subunit of voltage-gated calcium channels, is an orally administered gabapentinoid developed for the treatment of peripheral neuropathic pain in Japan , 16. ThiAlthough there are many positive reports associated with pregabalin, some patients have moderate adverse events . TetsunaThis retrospective study included outpatients with peripheral neuropathic pain who consulted our hospital between April 2019 and October 2019. Data were collected from medical records. The diagnosis of peripheral neuropathic pain was based on a history of neuropathic pain and confirmatory findings on examination. The inclusion criteria were a diagnosis of peripheral neuropathic pain based on the flow chart of the grading system for neuropathic pain , lack ofAt least 1 month after cessation from pregabalin, treatment with mirogabalin  was prescribed. The patients received mirogabalin 10 mg/day orally for the first week. In patients with decreased renal function, the dose of mirogabalin was decreased to 5 mg/day. Depending on patient age and symptoms, the dose of mirogabalin was decreased or increased as required to between 2.5 mg and 15 mg/dose twice daily. All patients visited the hospital at 1, 2, 4, and 8 weeks to ensure compliance with the study regimen. The patients with an adequate effect received the same dose of mirogabalin. In patients with an inadequate effect, the dose of mirogabalin was increased up to 30 mg/day. If adverse events were observed, the dose was decreased. In this study, no other conservative treatments  or surgeries were performed. During the study, only the dispensing pharmacist had knowledge of the patient codes. The manufacturer and provider of mirogabalin  was not involved in the protocol development, data collection and management, statistical analysis, or manuscript preparation.The neuropathic pain screening questionnaire (NeP score), developed by Ogawa et al., was used for the peripheral neuropathic pain survey Table  19–21].–21.19–21The primary endpoint of this study was to analyze the treatment course of peripheral neuropathic pain using NRS scores in patients receiving mirogabalin.The secondary endpoint of the current study was to investigate the adverse events of mirogabalin.p < 0.05 were considered significant. Statistical analyses were conducted using SPSS software version 25.0 for Windows .Factors associated with the cessation of mirogabalin treatment due to adverse events were identified using univariate analyses between the patients who continued treatment and those who ceased from treatment. Differences in the treatment course  were compared using one-way analysis of variance with Bonferroni post hoc tests. Moderate improvements in pain are considered to be 30%h Bonferroni postnivariate 50% pain relief is considered a good outcome , 24. TheOf the 337 outpatients with peripheral neuropathic pain who had been treated with pregabalin, 187 (55.5%) met the inclusion criteria and were included in this study Table . Adversep = 0.0017) and significantly higher incidences of dizziness (p = 0.015) and edema (p = 0.012) with pregabalin than those who continued mirogabalin. The patients who discontinued mirogabalin also had significantly higher incidences of dizziness (p = 0.0069) and edema (p = 0.016) than the patients who continued mirogabalin, and these effects contributed to the cessation of treatment.Fifty-nine patients received mirogabalin 10 mg/day orally for the first week, and 128 patients received mirogabalin 5 mg/day due to decreased renal function. Thirty-three patients were treated with 5 mg/day for 8 weeks of treatment. Eighty-one patients increased the dose of mirogabalin to 10 mg/day due to lack of efficacy. Thirty patients increased the dose of mirogabalin to 20 mg/day. Nineteen patients increased the dose of mirogabalin to 30 mg/day; none of these patients experienced severe adverse events with the increased dose. Twenty-four patients (12.8%) withdrew from mirogabalin treatment because of adverse events. Adverse events associated with mirogabalin included somnolence , dizziness , edema , epigastric pain , weight gain , and fatigue . We investigated factors associated with the cessation of mirogabalin treatment due to adverse events. There were no significant differences in age, sex, body mass index (BMI), or diagnosis between the patients who discontinued mirogabalin and those who continued its use . We examined whether there were differences in the adverse events and magnitude of NRS improvement between the patients with initial doses of 5 mg/day (n = 128) and 10 mg/day (n = 59). The incidence of adverse events in patients with an initial dose of 5 mg/day  was not significantly different from that in patients with 10 mg/day . There were no significant differences in the magnitude of NRS improvement between the groups with initial doses of 5 mg/day (46.5% ± 24.8%) and 10 mg/day . Similarly, there were no significant differences in the magnitude of NRS improvement in patients taking maximum doses of 5 mg/day (n = 47), 10 mg/day (n = 89), 20 mg/day (n = 32), and 30 mg/day (n = 19, p = 0.79; Fig. We also investigated changes in NRS scores over the course of treatment with mirogabalin for 8 weeks. After treatment with mirogabalin for 1 week, NRS scores significantly decreased compared with baseline (day n = 18 and 10 In this study, we used mirogabalin to treat patients with peripheral neuropathic pain who switched from pregabalin treatment to mirogabalin treatment due to lack of efficacy or adverse events. Mirogabalin is a new drug for the treatment of peripheral neuropathic pain, and to our knowledge, there have been no reports of its clinical outcomes for patients who were previously treated with pregabalin. Mirogabalin exerted a significant analgesic effect within 1 week and was associated with mild CNS adverse effects.Guidelines for the pharmacologic management of neuropathic pain recommend drugs acting at α2δ subunits of voltage-gated calcium channels, serotonin–norepinephrine reuptake inhibitors, and tricyclic antidepressants as first-line agents, neurotropin and tramadol as second-line agents, and opioids as third-line agents . SeveralIn vitro studies of its pharmacologic action have demonstrated that mirogabalin had a higher binding affinity for the human and rat α2δ subunit than pregabalin . In a diThe α2δ-1 subunit plays an important role in the onset and pathological persistence of neuropathic pain. Α2δ-1 expression levels correlated with tactile allodynia development were significantly increased in rats with spinal cord injury . KnockdoAlthough the results of the present study suggest that mirogabalin might be an alternative treatment option for the treatment of peripheral neuropathic pain, the present study has some limitations. First, both pregabalin and mirogabalin are ligands for the α2δ subunit of voltage-sensitive calcium channels. However, this study had no pretrial protocol and is a case series without a comparison or placebo group. We did not compare these two drugs in this study. Thus, the results cannot be clearly attributed to mirogabalin administration. Second, this study had a short observation period. Although most patients treated with mirogabalin for 8 weeks maintained their weight within ± 5% of their baseline weight, weight gain can be an issue with mirogabalin when used for a longer period. A third limitation was a lack of determination of the best screening questionnaire for neuropathic pain. Neuropathic pain screening questionnaires include painDETECT , the spiThis investigation indicated that mirogabalin is safe and effective for reducing peripheral neuropathic pain in patients who ceased treatment with pregabalin due to adverse events or lack of efficacy.


We aimed to evaluate pain scores one year after impar ganglion block in patients with coccydynia who did not benefit from conservative treatment.The medical records of 29 patients with coccydynia were reviewed. Patients who were referred to the algology clinic and underwent impar ganglion blocks were retrospectively evaluated. Demographic data, time to the onset of pain, causes of pain, X-ray findings, administered invasive procedures, and visual analog scale (pain) scores were recorded.p < 0.05). Furthermore, visual analog scale scores at the 3–6 months and 6 months-1 year periods were significantly lower in patients who received diagnostic blocks plus pulse radiofrequency thermocoagulation than in patients who underwent a diagnostic block only.A total of 29 patients were included in the study, 10 males (34%) and 19 females (66%). The average age and body mass index were 53.45 ± 9.6 and 29.55 ± 4.21 respectively. In 21 patients, the onset of pain was associated with trauma. Nineteen patients (65.5%) had anterior coccygeal angulation. The average visual analog scale score before undergoing an impar ganglion block was 7.4 ± 1. After the procedure, the scores at < 3 months, 3–6 months and 6 months-1 year follow-up intervals were significantly lower (The impar ganglion block provides effective analgesia without complications in patients with coccydynia. Pulse radiofrequency thermocoagulation combined with a diagnostic block prolongs the analgesic effect of the procedure. Coccydynia is defined as pain in the sacrococcygeal region. It is a disorder that not only reduces a patient’s quality of life, but it is difficult to treat . NumerouPatients with coccydynia typically complain of pain in the coccyx. This pain increases with prolonged sitting, leaning backwards during sitting, prolonged standing and standing up after being in a sitting position. Conservative treatments such as non-steroidal, anti-inflammatory drugs (NSAIDs), levator ani relaxation exercises, sitting cushions and transcutaneous electrical simulation have all been used to alleviate the pain, however these methods are ineffective in 10% of patients .The impar ganglion, also known as the Walther ganglion, is the terminal pelvic division of the sympathetic chain and is located behind the rectum, anterior to the sacrococcygeal joint and coccyx. It provides nociceptive and sympathetic innervation to the perineum . When coThe aim of our study was to evaluate pain scores in patients with coccydynia who underwent an impar ganglion block in our algology department due to the failure of conservative treatment over the course of a 1-year follow-up period.The medical records of 29 coccydynia patients treated with impar ganglion block at the algology department of Balikesir University Hospital were retrospectively reviewed. Age, gender, height, body weight, the onset of pain and its possible causes  were collected from medical records. X-ray images of the coccyx were examined to evaluate coccygeal structure and underlying physiology and potential pathologies. The images were classified as either normal or exhibiting anterior coccygeal angulation. Our study was approved by the institutional ethics committee (decision No: 2018/156).The number of impar ganglion blocks used on patients, the 0.25% bupivacaine+ 40 mg methylprednisolone mixture used, and the application of radiofrequency thermocoagulation (RFT) were recorded. Visual analog scale (VAS) pain scores were acquired from the records both before and after the procedures. The VAS scores were obtained during policlinic check-ups and phone calls at < 3 months, 3–6 months and 6 months-1 year time intervals following the procedure. Patients who were referred to surgery after the procedure were also recorded, along with their VAS scores.The impar ganglion block was performed using a 22-gauge needle from the midline. The tip of the needle and the spread of the radiopaque substance in front of the coccyx were observed using fluoroscopic lateral images with C-arm fluoroscopy assistance Fig. . Blocks p-value < 0.05 was accepted as statistically significant.Data was analyzed using IBM SPSS Statistics version 22 . Continuous data is expressed as averages and standard deviations and categorical data as frequencies and percentages. The Shapiro-Wilk test was used to evaluate the normal distribution of parameters. Comparisons of the data was performed using the Wilcoxon and Mann-Whitney U test. Parametric data is shown as average ± standard deviation (SD). Association among VAS score, gender, and body mass index was carried out using the Spearman’s correlation test. A Twenty-nine patients, 10 males (34%) and 19 females (66%) were included in the study. The average age, weight, height and body mass index (BMI) of all patients was 53.45 ± 9.6 years, 82.59 ± 12.12 kg, 166.21 ± 8.8 cm and 29.55 ± 4.21, respectively. Body mass index was over 25 in 23 of 29 patients (79.3%). The onset of pain was greater than 1 year in 23 (79.3%) patients and less than 1 year in 6 patients (20.7%) (Table Twenty patients (68.9%) underwent DB only, while 9 (31.1%) underwent DB+ pulse RFT. In all patients, a DB with a total of 10 ml of 0.25% bupivacaine+ 40 mg methylprednisolone was administered during the first procedure. The block was performed using either a transsacrococcygeal or intercoccygeal approach.p < 0.05) (Table The average VAS score before undergoing the impar ganglion block was 7.4 ± 1 and decreased to 5.2 ± 1.5 following the procedure. At the 3-month evaluation period, the average VAS score was 4.7 ± 2.1, and at the 3–6 month and 6 month-1 year evaluations the scores were 4.3 ± 2.4 and 4.2 ± 2.6, respectively. VAS scores were found to be significantly lower in patients at the 3-month, 3–6 months and 6 months-1 year follow-up evaluations (There was no correlation between VAS scores and gender or BMI.A 1-year follow-up of coccydynia patients demonstrated that the impar ganglion block procedure effectively controlled pain and that a DB + pulse RFT further prolonged analgesic efficacy. Coccydynia is a symptom with different causal factors including twisting of the sacrococcygeal joint or intercoccygeal segment, fracture, infection, tumor or degenerative changes . These fThe impar ganglion is the terminal division of the sympathetic chain located in the midline and, in contrast to other divisions, is the only solitary autonomic division. The definitive anatomic location of the impar ganglion remains uncertain but is considered to be anterior to the sacrococcygeal joint, coccyx or distal end of the coccyx . DiffereCoccydynia occurs more frequently in females. While it can occur at any age, the incidence increases in people over forty . ConsistGündüz et al. noted that trauma, especially after a backwards fall, was the cause of coccydynia in 50% of patients . SimilarPain relief can be achieved with conservative medical treatment in 90% of patients with coccydynia , 17. PatRadiofrequency treatment is a percutaneous and minimally invasive procedure that can be used in coccydynia patients who do not benefit from appropriate medical treatment and physiotherapy. It is more selective compared to phenol and alcohol neurolysis and leads to fewer complications. Reig et al. reported impar ganglion blocks with RFT as useful for non-malignant perineal pain . SimilarSerious complications such as rectal perforation, hemorrhage and infection, along with difficulties in implementing the technique, restrict the popularity of this highly effective block . In all Surgical excision of the coccyx for the treatment of coccydynia is the option of last resort and is performed only if all other treatments have failed. High complication rates and failure to relieve pain have been reported with this procedure, but its overall success rate is between 51 and 90% , 20. In Limitations to our study include its relatively small sample size and the retrospective nature of the review. The impar ganglion block provides effective pain relief without complications in patients with coccydynia. Diagnostic blocks combined with pulse RFT achieved prolonged analgesic efficacy. However, prospective randomized studies involving larger sample sizes are needed to reach more conclusive results regarding the effectiveness of these procedures.İn conclusion, impar ganglion block is an effective procedure with low complication rate for pain relief in coccydynia. The analgesic effect can be prolonged by combining the DB with pulse RFT.


Low back pain (LBP) is a common illness that has potential sources, like intervertebral discs, facets and sacroiliac joints (SIJ). Primary source of pain in 10% to 27% of patients with mechanical LBP is SIJ which is a true diarthrodial joint; separated by a joint space containing synovial fluid and a fibrous capsule. Several mechanisms of injury may cause SIJ pain such as a direct fall on the buttocks, motor vehicle accident, and an unanticipated step into a hole or from a miscalculated height , this cross-sectional study was conducted at different taxi stops of Tehran in 2018. Participants with radiation of pain towards lower limb, having postural dysfunction or limb length discrepancy, with recent history of surgery, trauma or pathological disease were excluded from the research.Overall, 700 male taxi drivers, aged between 20–60 yr with work experience of more than one year were interviewed to fill questionnaires. Patients rate their current pain intensity from 0 (“no pain”) to 10 (“worst possible pain”) by using Numeric rating scale (NRS). The mean age, height and weight of the participants were 47.40 ± 8.90, 172.13 ± 6.05, 81.89 ± 10.77 respectively. All the participants were males and majority (96.5%) of them had right dominant hand. Most of the drivers had acquired high school (35.1%) or intermediate (45.4%) education. Only 235 (39.5%) had the habit of exercising and 248 (47.1%) used to do daily stretching exercises. Majority of the drivers, 463 (77.8%) showed no sleep disturbance and almost half of them (47.1%) were smokers.Among 595 valid questionnaires, 219 reported LBP and were invited at physiotherapy clinic, in School of Rehabilitation to assess their SIJ. A different physiotherapist, blinded with the outcomes of the research, had performed physical assessment by applying five provocative tests for SIJ which included distraction test, thigh thrust, Flexion, Abduction and External Rotation (FABER), compression and Gaenslen’s Maneuver and studies have suggested that a battery of three or more provocation tests can predict SIJ dysfunction .P=<0.001) with SIJ dysfunction. Trauma or smaller, repetitive stresses may damage the bones, ligaments, muscles and nerves of the SIJ  had SIJ dysfunction on left side while 27(12.3%) of them had it on right side. Mean pain intensity was 4.79 and it was significantly associated (Metabolites elimination and heat dissipation are essential to maintain homeostasis within muscle fibers which require sufficient blood flow. Static contractions cause marked impairment in blood flow to the muscles which might be the main explanation for muscle fatigue during isometric contractions, no matter how low the contraction . Therefo


Telephysiotherapy (TPT) is a provision of physiotherapy services at a distance, using telecommunication technology when an in-person visit is not a feasible option. The objective of this study was to investigate the effectiveness of TPT in management of pain caused due to various problems among patients living in rural areas of a developing country.  This retrospective study conducted in rural areas of Nepal recruited all patients who met the eligibility criteria during a day campaign. Two physiotherapists, one for assessment and another for treatment, were involved. Based on pretraining assessment finding, evidence-based individualized physiotherapy was prescribed. Pamphlets containing pictures of the prescribed exercises and instructions in the Nepali language were distributed. The treating physiotherapist made telephone calls to every patient each week to give necessary information, correction, modification, and progression of the exercise whatever required. At the end of the second and fourth weeks, pain was assessed using the Numeric Pain Rating Scale (NPRS) through telephone calls. The data were analyzed using ANOVA with repeated measures followed by pairwise comparisons. F = 3.5, p = 0.04, when worst: F = 26.4, p < 0.001, during activities of daily living: F = 16.6, p < 0.001, and during occupation: F = 15.6, p = 0.001) across time. The result met the minimal clinically important difference of NPRS, which is 2.  Fifteen patients having pain due to various conditions participated in the study. The NPRS demonstrated significantly decreased pain (at rest:  The telephone-based TPT interventions demonstrated significant reduction in pain caused by various musculoskeletal problems. It could be a feasible and effective treatment option for the patients living in rural areas. However, we recommend for large-scale trials to establish effectiveness of the intervention and for its implication into routine clinical practice. Telephysiotherapy (TPT) is a provision of physiotherapy services at a distance, using telecommunication technology such as video conferencing or telephone meeting, when an in-person visit is not a feasible option . TPT empPatients who live far away from the clinics may find it difficult to attend the clinic regularly due to distance and cost of transportation . In ordeIn the context of developing countries like Nepal, TPT through Internet or video conference call is not possible due to feasibility issue as well as low literacy rate. So, simple telephone-based calls and understandable therapeutic materials  are the best means . HoweverThe TPT has already shown effectiveness in improving clinical outcomes in developed countries , 10, 11,This was a retrospective study that included 15 participants suffering from pain due to prolapse intervertebral disc, tennis elbow, rheumatoid arthritis, and mechanical low back pain, traumatic ankle pain, and neck pain visiting Manekharkha and Bahunepati outreach centers, which are located in two rural municipalities of Nepal. These two centers are the outreach centers of the Dhulikhel Hospital, which were selected due to high need of physiotherapy services in their catchment areas. We included all patients from the 2-day camp who (a) visited outreach centers due to pain , (b) had those health conditions for which flyers or pamphlets in the Nepali language including pictures and instructions for physiotherapy treatment were available with our physiotherapists, (c) were educated (patients or primary caregivers who were able to read and follow the given instructions), (d) had mobile phone to reach them (patients or primary caregivers) and were able to communicate. Those who had hearing problems, severe comorbidities including depressive symptoms , and were not willing to give consent were excluded from the study. The mode of communication was through a mobile phone, the use of which has widely penetrated the rural settings, which is affordable, feasible, and has become an essential mode of telecommunication in Nepal .Informed written consent was obtained from the patient/caregiver for possible use of the data in research. Assessment was taken as part of the routine work. Two physiotherapists, one for assessment, called the assessor, and another for treatment, called the treatment provider, were involved.http://www.jfmpc.com/temp/JFamMedPrimaryCare761327-5192845_142528.pdf). The context and cultural background of the participants included in the postearthquake rehabilitation and in the present study was similar. Both were from the similar communities of the same district [The preplanned treatment protocol for various conditions consisted of evidence-based basic physiotherapy techniques that were derived through the literature review, and it was previously applied for rehabilitation of postearthquake victims . This prdistrict .The physiotherapist who provided the treatment made telephone calls to each patient/caregiver every week  and gave necessary information, correction, or modification of the prescribed exercises when needed. Progressive intervention was prescribed and provided when appropriate. Everything was guided according to the pamphlets that were provided to the patients and caregivers in advance. At times when the patient or caregiver could not understand any exercises or their progression, they were suggested to go to their nearby outreach center to take support from the health assistants who were also trained during the campaign at the first session. Nearby health assistants were trained with an aim to make the training program sustainable.Telephone-based TPT was selected in this study because sophisticated communication media like real-time video conference and high-speed Internet are not widely available in developing countries . Mobile r = 0.79–0.92) of this tool have been established with 100% agreement between two raters scoring the 0–10 point NPRS [r = 0.86) and correlation between NPRS and the Verbal Descriptor Scale (r = 0.88). NPRS has adequate construct validity correlation between NPRS and the Verbal Rating Scale (Spearman's r = 0.38) [The Numeric Pain Rating Scale (NPRS) was selected as an outcome measure to access pain intensity. The NPRS is an 11-point scale from 0–10 where “0” = no pain and “10” = the most intense pain imaginable. In this scale, patients verbally select a value that is most in line with the intensity of pain that they have experienced in the last 24 hours. A written form is also frequently used with the numeric values of 0–10 written out. The NPRS has good sensitivity while producing data that can be statistically analyzed . Excelleint NPRS . It has  = 0.38) , 19. In  = 0.38) .At the end of the second and fourth weeks, the patients were called through a mobile phone and the assessor evaluated pain using the Numeric Pain Rating Scale. During the campaign, patients, their caregivers, and health assistants of nearby outreach centers were instructed and well trained for scoring their pain in NPRS. At times, when patients had confusions, they used to seek help from caregivers or health assistants. So, we did not encounter any issues regarding administration of the outcome measure.p value > 0.05), the data were analyzed using one-way ANOVA with repeated measures. Mauchly's test was used to find the sphericity. Whenever sphericity was not met, the Greenhouse–Geisser factor was applied. Pairwise comparison was done, and the Bonferroni factor was applied to adjust for multiple comparisons. The significant level was considered at p value < 0.05. The data were analyzed using SPSS version 21.0.Descriptive statistics were used to describe clinical and demographic characteristics of the participants. Since all the dependent variables were normally distributed  or due to prolapsed intervertebral disc (PIVD) (20%), was the major issue followed by knee, ankle, or elbow pain. Majority of the participants (53.3%) had pain between one and three months. All participants had musculoskeletal pain. All participants were from the adult age group. Both genders with age ranged between 36 and 70 years with the mean of 52.8 (SD: 11.56) participated in the study .The main occupation of all participants was farming. They used to work in the field for about 6–8 hours and do households work for about 2–3 hours per day. Children of 12 participants (80%) were living in the city or abroad for education or work. During this study, none of the participant reported to having medication specific to pain management. Long duration of work was an aggravating factor, and rest was the relieving factor for all the participants.F = 3.5, p=0.04). Similarly, we found that mean NPRS for pain when worst , for pain during ADL , and pain during occupation  all demonstrated significant difference between three points of time. When stress due to pain was measured in the form of NPRS, the mean score also demonstrated significant difference  between three points of time.As depicted in p=0.02), pretraining to posttraining week 4 (p < 0.001), and posttraining week 2 to posttraining week 4 (p=0.009). Similarly, as shown in p=0.06).The post hoc tests using the Bonferroni correction revealed that telephysiotherapy elicited significant reduction of pain when worst from pretraining to posttraining week 2 (p=0.05) on all continuous outcome variables.We had participants with the heterogeneous age group. When we analyzed in two age groups (<60 years versus ≥ 60 years), there was no significant time and age group interaction  or subacute (≥1 month to 3 months) or chronic (>3 months) , the majThough we did not measure the multidimensional aspect of the pain, the religious, environmental, cognitive, and neurophysiological aspects might not have much effect, as all the participants were from the same community and had similar contexts and background. Furthermore, our objective was to explore the feasibility and outcome in general and convert the routine work into research. So, measuring many aspects of pain was beyond the scope of this study. To minimize influence of various multidimensional factors of pain, we had excluded participants with depressive symptoms, counseling session was integrated in the treatment session, and all interventions were selected in patient-therapist collaboration. However, it is important to examine the effect of multidimensional factors on pain management through telephysiotherapy in future studies.TPT is advancing rapidly in developed countries where patients are digitally connected . To our Our study also has some limitations. First, this retrospective study was conducted in a relatively small sample without a control group for comparison. Second, we could not measure exercise adherence. Variation in exercise adherence might have affected the result because patient perspectives and preference may differ between TPT versus face-to-face physiotherapy. Finally, there were no comparable published data on the effect of TPT among individuals with pain due to similar conditions we included in our cultural context and background. Therefore, comparisons were made on the findings of this study with the similar studies.Telephone-based TPT intervention demonstrated significant reduction in pain caused by various musculoskeletal problems. Therefore, TPT is feasible and helpful in management of pain due to various musculoskeletal conditions in individuals living in rural areas who have barriers to accessing health centers daily. The findings of our study would be applicable in low-resource countries like Nepal. We recommend large-scale randomized controlled trials for future research to establish effectiveness of the intervention and its implication into routine clinical practice.


Mirizzi syndrome is an uncommon complication of longstanding gallstone disease. Pre-operative diagnosis is challenging, and to date, there is no consensus on the standard management for this condition. Until recently open cholecystectomy was the standard of care for type II Mirizzi syndrome (McSherry classification). The objective of this study was to assess the incidence and management of type II Mirizzi syndrome in patients with proven or suspected choledocholithiasis undergoing laparoscopic common bile duct (CBD) exploration and present our experience in the laparoscopic management of this rare condition over the last 21 years.Prospective data collection of eleven cases of type II Mirizzi syndrome amongst a series of 425 laparoscopic bile duct explorations was performed between 1998 and 2019. Demographic, clinical, diagnostic, intra-operative, and post-operative data were recorded.n = 3, antegrade stent n = 5, transcystic drain n = 2), and in one case a non-drained duct was closed with Endoloop. Stone clearance rate was 100% (11 cases). In two patients the transinfundibular approach was used in conjunction with holmium laser lithotripsy to enable choledochoscopy and successful stone clearance. Three patients were complicated in the post-operative period with bile leak (n = 2) and lower respiratory tract infection (n = 1). An incidental gallbladder carcinoma was found in one patient.The incidence of type II Mirizzi syndrome was 2.6% in 425 laparoscopic CBD explorations. All operations were completed laparoscopically with closure of the defect over a decompressed CBD (T-tube Laparoscopic management of type II Mirizzi syndrome is feasible and safe when performed by experienced laparoscopic foregut surgeons. Laparoscopy and choledochoscopy can be combined with novel approaches and techniques to increase the likelihood of treatment success.The online version of this article (10.1007/s00464-019-07316-6) contains supplementary material, which is available to authorized users. Mirizzi syndrome is an uncommon condition due to longstanding gallstone disease. It was first described by Kehr in 1905 and by Ruge in 1908 as a rare form of obstructive jaundice caused by external obstruction of the bile duct following impaction of a stone in the cystic duct with associated inflammation . This coSince the description of its pathophysiology multiple classifications have been made, but McSherry’s and Csendes’ classifications are currently in wide use , 9. McShPre-operative diagnosis of this condition is challenging, as there are no pathognomonic signs or symptoms. Obstructive jaundice and abdominal pain are the most frequent symptoms found in these patients , 10. DiaThe objective of this study was to assess the incidence and management of type II Mirizzi syndrome in patients with proven or suspected choledocholithiasis undergoing laparoscopic common bile duct exploration (LCBDE) and report our experience of the laparoscopic management of this rare and complex complication of gallstone disease over the last 21 years.A retrospective review of a prospectively maintained database of 425 consecutive patients who underwent LCBDE at a single centre between February 1998 and April 2019 was performed. Ethical approval was not required for this type of study. Based on McSherry classification, all type II Mirizzi syndrome patients were included for further analysis. All operations were performed or supervised by the senior surgeon (AI). All patients were assessed with pre-operative liver function tests (LFTs) and abdominal imaging: US, CT and/or MRCP. Four patients underwent pre-operative ERCP. Data collected included pre-operative demographic information and pre-morbid status, clinical presentation, pre-operative investigations, intra-operative findings  and post-operative outcomes. Outcomes of this study were successful access to the CBD for choledochoscopy, successful stone clearance (if required), restoration of normal anatomy, conversion to open surgery, post-operative complications, and length of post-operative hospital stay. Normally distributed data are reported as mean (with standard deviation), whereas skewed or ordinal data are reported as medians. Categorical variables are expressed as number and frequencies (%).The French technique was used for positioning patients, with the surgeon standing between the legs and the assistant to the left side of the patient. A 5 mm 30° scope was sited through the abdominal wall at the level of the insertion of the ligamentum Teres to obtain an optimal view of the CBD and Calot’s triangle. A 5 mm Nathanson liver retractor was inserted in the epigastrium to maintain the operative view when necessary . When noDuring the study period, 425 patients underwent LCBDE. Eleven patients were included after intra-operative findings fulfilled the diagnostic criteria for type II Mirizzi syndrome (McSherry classification).n = 4), ASA 2 (n = 5), and ASA 3 (n = 2). Pre-operative morbidity included hypertension (n = 5), hypercholesterolaemia (n = 3), diabetes mellitus (n = 2), ischaemic heart disease (n = 1), chronic pulmonary respiratory disease (n = 1) and asthma (n = 1). The most frequent clinical presentation was jaundice (n = 7). Two patients presented abnormal LFTs  and another two patients with a dilated CBD on pre-operative imaging . Pre-operative studies included US (n = 9), CT (n = 4), MRCP (n = 6), and ERCP (n = 4) (Table n = 1), inability to clear CBD stones (n = 1), inability to image and stent the CBD and perform sphincterotomy (n = 1), and inability to pass a guidewire due to bile duct stricture (n = 1). The sensitivity for preoperative diagnosis of Mirizzi syndrome by ERCP was 0% in our series. IOC was performed in four patients, with evidence of CBD stones in all cases, which were successfully removed with choledochoscopy and standard retrieval techniques.The male to female ratio was 3:8 and the median age was 45 years old. Pre-operative assessment of fitness for surgery adopting the American Society of Anaesthesiologists (ASA) classification was as follows: ASA 1 (n = 9) or infundibulum (TIA) (n = 2)  (TIA) n =  (Table 22) Table .Table 2In = 3)    5) Fig.  or a choFig. n =  n = 2, 18%) and lower respiratory chest infection . All three complications were Clavien–Dindo grade 2 and managed conservatively. The International Study Group of Liver Surgery (ISGLS) published severity grading of bile leakage after hepatobiliary and pancreatic surgery [p = 0.06). The median length of hospital stay was 5 days  due to high risk of biliary injury (up to 22%) during dissection of the cystic duct and artery in an inflamed, distorted hilum and high conversion rates to open surgery (11.1–80%) , 29–34. The laparoscopic approach is safe and feasible for the treatment of type II Mirizzi syndrome. New approaches such as TIA and complementary techniques (e.g. LABEL) can be useful in the management of complex cases, avoiding choledochotomy or fistulotomy and their associated complications. Use of TIA may result in fewer cases of type II Mirizzi syndrome being identified intra-operatively and therefore accurate pre-operative diagnosis is important. Surgeons performing LCBDE for proven or suspected choledocholithiasis should be aware of the relatively high incidence of type II Mirizzi syndrome within this population and possess the necessary laparoscopic expertise.Supplementary material 1 (MP4 276843 kb)Below is the link to the electronic supplementary material.


Systematic review and meta-analysis.This study aims to evaluate the effects of anterior cervical decompression and fusion(ACDF) on axial neck pain in adult patients receiving surgery for myelopathy,radiculopathy, or a combination of both.Two independent reviewers completed a librarian-assisted search of 4 databases. VisualAnalogue Scale (VAS) and Neck Disability Index (NDI) scores were extractedpreoperatively and at 3, 6, 12, 24, 36, 48, and 48+ months postoperatively for ACDFgroups and pooled using a random-effects model.P < .0001 for all endpoints). Individual NDI meandifferences were reduced at 6 weeks (−26.7 [−30.9 to −22.6]), 3 months (−29.8 [−32.7 to−26.8]), 6 months (−31.2 [−35.5 to −26.8)], 12 months (−29.3 [−33.2 to −25.4]), 24months (−28.9 [−32.6 to −25.2]), 48 months (−33.1 [−37.4 to −28.7]), and >48 months(−37.6 [−45.9 to −29.3]) follow-up .Of 17 850 eligible studies, 37 were included for analysis, totaling 2138 patientsanalyzed with VAS and 2477 with NDI score. Individual VAS mean differences were reducedat 6 weeks : −3.5 to −1.6]), 3 months (−2.9 [−3.7 to−2.2]), 6 months (−3.2 [−3.9 to −2.6]), 12 months (−3.7 [−4.3 to −3.1]), 24 months (−4.0[−4.4 to −3.5]), 48 months (−4.6 [−5.5 to −3.8]), and >48 months (−4.7 [−5.8 to−3.6]) follow-up (ACDF is associated with a significant reduction in axial neck pain compared withpreoperative values in patients being treated specifically for myelopathy orradiculopathy. This influences the preoperative discussions surgeons may have withpatients regarding their expectations for surgery. The effects seen are stable over timeand represent a clinically significant reduction in axial neck pain. While myelopathy may improve with surgery, the results arevariable so the general goals of the procedure are to halt progression.16 Radiculopathy, however, tends to improve more reliably so patients anticipatereliable reductions in arm pain.3Anterior cervical discectomy and fusion (ACDF) is a procedure that may be performed forpatients with degenerative spondylitic myelopathy or radiculopathy. While the specificindications for surgery vary depending on patient symptoms and anatomic considerations suchas previous surgery or deformity, there are well-recognized guidelines for treatment.While axial neck pain symptoms are particularly troubling to many patients, the effects ofACDF on axial neck pain are more poorly understood. Whereas several studies report areduction in axial neck pain following ACDF, there have been no meta-analyses to dateexamining the effects of ACDF on cervical spondylitic myelopathy and/or radiculopathy.Accordingly, preoperative discussions may lack clarity regarding the outcomes of surgerywith regard to the prognosis of axial neck pain. Therefore, the purpose of thismeta-analysis is to examine all randomized controlled trials and prospective cohort studiesthat recorded preoperative and postoperative axial neck pain scores in order to examine theeffect of single-level ACDF on axial neck pain in patients with myelopathy and/orradiculopathy.This systematic review included adult patients receiving ACDF. The inclusion criteria forthis review were the following: (1) published online and in the English language; (2)randomized controlled trial or cohort study; (3) included preoperative and postoperativedata on subjective midline axial neck pain scores ; (4) single-level pathology. All studies involvingcorpectomy or multilevel anterior decompressions, as well as posterior decompressiveprocedures, were excluded. In multiple cases there were studies published with what, inthe authors’ best judgement, appeared to be the same ACDF data as a previously publishedcontrol arm for disc arthroplasty versus ACDF trials. In these cases, the most recent datawas utilized and the earlier studies by these authors were not included.Two independent authors searched MEDLINE, EMBASE, PubMed, and Cochrane databases with theguidance of a professional librarian using the following terms: “anterior cervicaldecompression and fusion” OR “ACDF,” OR “cervical decompression” AND “axial neck pain” OR“midline neck pain” to broaden the number of studies retrieved. Initial search resultswere vetted for duplicates and a title screen was performed for relevance. Reference listsof eligible studies were screened for additional studies meeting eligibility criteria.Discrepancy was resolved with discussion and consultation with the senior supervisingauthor.The risk of bias of included studies was assessed by using the Methodological Index forNon-Randomized Studies (MINORS) scale. The MINORS scale scores vary from 0 to 24 for riskof bias. The use of this scale is appropriate because the randomization process of thetrials did not apply to this review as only data from the ACDF trial arms wereextracted.Two independent reviewers collected data into Excel spreadsheets. Demographics, type andstudy risk of bias, mean preoperative and postoperative VAS and/or NDI scores wererecorded at multiple points in time . Research ethics board approval is not required as it examinesdata from published studies. Therefore, there are no concerns regarding patient privacy orparticipant ethics.2test and quantified by I2 statistics. The overall pooled meanchange in pain scores with 95% confidence intervals (CIs) over 24 months and heterogeneityare reported. Comprehensive Meta-Analysis version 3.3.070 was used for meta-analysis.Demographic data is pooled for age, gender, smoking status, and NDI and VAS scores. Thepooled proportions and pooled mean with standard deviation are reported. Some studiesutilized a 100-point VAS neck pain scale while others utilized the more traditional10-point scale. These scores are documented in the tables as reported by authors; however,the 10-point scale was selected for formal analyses and the 100-point scores weretherefore divided by 10 to standardize the pain score from 0 and 10. In order to evaluatethe mean change in pain scores, the mean pain scores from the preoperative assessment andat each follow-up visit were pooled from 32 included studies. The pooled means werecompared to preoperative pooled means at each follow-up visit by use of a random-effectsmodel with inverse variance. Between-study heterogeneity was tested using χ440 Individual studies are presented in Initial librarian-assisted search revealed 17 850 studies, which after deletion ofduplicates and initial title screen for relevance left 3740 studies for abstract review. FollowiStudies range in year from 1998 to 2017. A total of 2138 patients are analyzed with regardto VAS scores and 2477 patients with regard to NDI scores. Fifty-three percent ofparticipants were male. Average time to final follow-up ranged from 6 months to 120 monthsfor VAS (mean 33.1 ± 23.9 months) and NDI data (mean 34.5 ± 23.8 months).Each of the 37 studies underwent risk of bias by MINORS scale. The mean MINORS score was19.9 (±2.2) and ranged from 13 to 23 indicating that the risk of bias was overallacceptable for most of the included studies. P < .0001;I2 = 99.9%; Figure A1), −2.94 , respectively.At every time point there was a statistically significant decrease in both VAS and NDIscores. Individual VAS mean differences are reduced compared postoperative scores at 6weeks, 3 months, 6 months, 12 months, 24 months, 48 months, and >48 months follow-upwere −2.52 ,−29.76 , respectively.Individual NDI mean differences at 6 weeks, 3 months, 6 months, 12 months, 24 months,48 months, and >48 months follow-up were −26.73  are the smallest effects that a patient wouldconsider beneficial to justify a procedure4446 included a total of 166 patients showing a 50% to 60% decrease in axial neck pain at4-year follow-up and patient satisfaction rates ranging from 56% to 79%.3 Functional outcomes were improved between 32% and 52% from baseline.3While this study reports clinically meaningful and statistically significant reductions inneck pain following ACDF, we do not recommend ACDF for neck pain in the absence of currentlyaccepted indications for surgery. Selection bias is present as included patients wereenrolled due to the presence of cervical myelopathy or radiculopathy. Accordingly,interpreting a causal relationship between ACDF and neck pain in the absence of neuralcompression warrants caution. One group of surgeons from Washington University report asystematic review on 3 case series utilizing ACDF for the purpose of mechanical/axial neckpain in patients without radiculopathy or any other standard indications for the procedure.They were criticized by editorial staff for presenting limited data to produce a meaningfulanalysis; however, they are commended for venturing beyond the accepted standards for thisprocedure. The 3 studies they reportedFuture research may attempt to understand the direct relationship between ACDF and axialneck pain in patients with single-level disc disease. It is unethical to randomize patientsto surgical treatment for neck pain, as ACDF is not accepted as a treatment for thiscondition. However, the current treatment guidelines for myelopathy suggest that mildmyelopathy may be treated conservatively or surgically. Therefore, clinical equipoise existsto design a study examining patients with mild myelopathy, with and without axial neck pain,to determine the treatment effects of ACDF on axial neck pain directly. The degree to whichaxial neck pain is affected by other treatments for myelopathy  remains to be determined. It would be usefulfor future research to fully characterize the effects of these procedures on axial neckpain.There are multiple strengths in this meta-analysis. A thorough search strategy is used withvarious keywords and a comprehensive search of multiple databases is undertaken. There aremultiple reviewers involved in the process of article retrieval, risk of bias assessment,and data abstraction to ensure accuracy and minimize bias. The included studies aremulticenter trials, including multiple implant products and surgeons, which increases thegeneralizability of our results. While we demonstrate high levels of heterogeneity in ouroutcomes at several time points, a large majority of studies were in favor for ACDF for areduction in axial neck pain. Accordingly, we do not consider this inconsistency intreatment effect to weaken our study’s conclusion.Our results indicate that ACDF is associated with a significant reduction in axial neckpain compared to preoperative values in patients being treated for myelopathy orradiculopathy. These effects meet clinically significant MIDs and may influence patients’expectations for surgery. These results may help clarify expected surgical outcomes inpreoperative discussions.Click here for additional data file.ACDF_Supplementary_Files for The Role of Anterior Cervical Discectomy and Fusion onRelieving Axial Neck Pain in Patients With Single-Level Disease: A Systematic Review andMeta-Analysis by Colby Oitment, Tracy Watson, Victor Lam, Mohammed Aref, Alex Koziarz,Edward Kachur, Jetan H. Badhiwala, Saleh A. Almenawer and Aleksa Cenic in Global SpineJournal